During this live webinar, we will discuss providing eye care to individuals with visual and/or multiple disabilities, as well as available resources and supports. This lecture aims to provide primary care optometrists with clinical pearls to be able to gather clinical information in a meaningful way that is comfortable for both the provider and patient.
Lecturer: Dr. Jem Martin, OD, New England College of Optometry (NECO), Massachusetts, USA
Alright. Good morning, everyone, or afternoon depending on where we are at. Thank you so much for joining me today. I’m very excited to be speaking about a topic that’s very near and dear to me today, which is individuals with disabilities and providing eye care to them.
As an introduction, my name is Jem Martin. I’m an optometrist located in Boston, Massachusetts and a faculty member at the New England College of optometry.
There are no disclosures for this presentation, and I’ll be largely pulling from my clinical experience, which is at Perkins School for the blind low vision clinic. Where we see mostly pediatric patients that have visual and multiple impairments.
So, when I was kind of putting this presentation together, I wanted to think about barriers, not only the ones that the patients face when getting how health care, but ones that provider space as well and being able to provide that health care. I wanna start from the patient’s point of view where they report difficulties regarding communications, attitudes being treated by healthcare providers, as well as difficulties with financial and transportational barriers, and finally just the scarcity of service in the area that they can access it in.
From the provider side, there’s some similar concerns regarding communication with the patients, as well as lack of training, and resources to provide care to this population.
Other barriers, including physical space, as well as the healthcare system as a whole, can also provide barriers to being able to provide the care that we want to provide.
And as we kind of start thinking out, I’d love to hear from you all some of the barriers to care that you most identify with.
Be that the communication, lack of training, lack of resources, physical barriers, or just barriers within the healthcare system in general.
Alright. Looks like a good even spread across the board with lack of training being one of the top ones. Hopefully, after today we can have a better idea of how to better communicate with these patients, as well as be able to find resources, and be able to interact with them in a way that’s comfortable for everyone involved.
Oftentimes I’m asked why work with this population?
And we know that there’s several different conditions that can be associated with ocular manifestations.
For instance, the autism spectrum can of course have refractive error and strabismus or eye turns, but we can also see functional deficits such as ocular motor difficulties visual perceptual deficits as well as difficulties regarding visual attention.
For the genetic condition, Trisony twenty one or also known as down syndrome, we still see significant refractive errors, as well as keratoconus giving significant A astigmatism correction needed. We also see some structural difficult changes such as a higher incidence of blepharitis and dry eye. As well as early onset cataracts and brush filled spots, which are an accumulation of iris connective tissue that can be seen on the iris pictured here at the bottom. And then of course we still see strabismus as well as accommodative dysfunction in common within this population.
S cerebral palsy is a group of disorders affecting the development of movement and posture. That can cause a lot of limitation as it comes to activities. It’s often attributed to disturbances within the developing fetal or infant brain.
Ocular manifestations again can include refractive errors as well as structural changes such as optic atrophy.
Strabismus, gaze, policy, and nystagmus are also highly correlated with individuals with cerebral palsy, as well as the brain based visual impairment called cerebral visual impairment or CVI.
Of these three, especially within down syndrome, we often see a lag of accommodation or under focusing it near. Within down syndrome, we see that there’s a decoupling between that accommodation and convergence and then their triad.
While they are able to converge, that accommodation lags behind and doesn’t kick in as much as it should. There’s still a lot more research to kind of be done within this area to determine if it’s more of a central processing difficulty or related to acuity or something else.
There are of course a number of other inherited syndromes and genetic disorders that have ocular manifestations.
We see a significant amount of hyperopia in patients who have fragile x syndrome, which is often seen in patients with autism.
Of course there’s also strabismus as we see in autism as well.
Prader Willie Syndrome, another multisystem genetic condition, we can see nystagmus for business, and a more higher instance of myopia.
Beyond specific conditions, you can also have multi sensory impairments, such as those who are deaf blind. About ten percent of children with visual impairments are also have hearing impairments, with a majority being related to usher syndrome.
Of course, the ocular disease within usher syndrome is retinitis pigmentosa.
Often, these patients will need a more tactile approach in exploring their world, as well as in communicating with them.
Finally, we also see several behaviors that individuals with disabilities may have that can affect their eyes ranging from things like eye rubbing or other injury around the eyes as well as light gazing.
So now we kind of have an idea of some of the ocular manifestations that we can be looking for in some of these patients. We want to think about the behaviors that they may have and the potential limitations due to their impairments.
In that vein, it’s important for us as examiners to be able to adapt our approach in gathering the exam information to better match where the patient is. It really makes a more comfortable exam not only for the patient but for the provider as well.
As the provider, This really starts with setting yourself up for success. You’ll want to make sure that your outfit lets you move around as you might not be just sitting in your exams here, but moving around the room. Throughout the examination as well.
A lot of times you’ll wanna be sure that you have long hair tied back. We’re not wearing ties or dangling jewelry. As it can be a chance that things can be grabbed and yanked and pulled towards you, which we don’t want.
Oftentimes, we really have to think outside the box and come up with different approaches.
This means that we’ll have to be sure to keep a number of different tools within our toolbox, so that way we can use and adapt them as needed based on the patient that presents.
I often find that reflection on the examination really sets me up for future success, success interactions that went well, of course, are always great to keep in mind in order to use it again in the future, especially those failures that you have and considering why it didn’t go well and how you can change your approach in the future. When I was first starting off working with patients who were no light perception, I would just start the exam being like, do you see the light on? Do you see the light off? And I had a rather upset teenager who was telling me that I’ve never seen light before, why are you asking me this? And now whenever I approach things testing with lights, I instead have a conversation with them and just chat about how they’re doing. While occasionally asking about the presence of lights. That way it’s not completely focused on their visual impairment.
As several of our patients may have visual impairments, I just wanted to touch briefly on some best practices which includes identifying yourself whenever you enter the room. I often have all the interns that I work with go around and introduce themselves to the patient as well. You’ll want to let them know when you’re leaving the room so that way they know that you have gone. It’s really important that you continue to speak directly to the patient and allow for them to have time to respond.
Marrating, what you’re doing is very helpful to orient them. And you wanna be sure to use specific directional language in order for them to better have an idea of where things are related around them.
Finally, using language such as see this or look at that is typical and you’re I would encourage you to continue using it as it’s often used in a typical conversation.
Communication approaches may need to be changed during these examinations.
You will want to allow for the patient to have some time to process what you have said, as well as time to respond to the question that you asked. This can vary between seconds to minutes and sometimes finding out that latency interval is important in order to engage the patient.
When you want to establish rapport with the patient as well as their team, I often joke around with my patients throughout, be sure to give high fives or elbow bumps.
And often you’ll want to rely on the caregivers are coming with the patient as they know that individual best. I’ll often ask approaches such as, hey, will they do well with lights? Should we use eye drops? What would be the best approach to make them comfortable and to make everyone as a part of the examination.
Being able to do this will allow you to better engage with the patients which is our goal as the examiners.
We want to really be able to adapt the examination so that way the patient can take part in the task.
This is important as we don’t want to put the blame on the patient for not being able to take part in the test that is not accessible to them and instead calling them uncooperative.
Instead, we should find a way as examiners to engage the patient with the task or make a note that we were unable to.
As we get into the exam before things kind of start, it’s very helpful to have some records to give an idea of your patient profile.
This conclude other records from other eye care providers, ophthalmologists, oculists, opticians, etcetera.
As well as for medical providers and educational or vocational reports.
Knowing educational goals can be helpful to assess the visual aspect of things, especially for those that are still within the educational system, such as knowing their reading requirements, the distance that their tests are often at, and what their future plans are after they leave the educational system.
As there are so many different conditions out there, it’s really impossible to know about every single one of them. Having these reports though can give you an idea of diagnosis that the patients have, and often I refer to the national organization for rare disorders or rare diseases dot org.
That provides a overview of what the condition is, as well as provide specific signs and symptoms that can be found in different symptoms. From there, I can see that there are any ocular manifestations that I need to know about. And then from there I know what to look for in the examination.
Once the patient arrives, you can then go over with them and they’re team any ocular concerns that they may have or changes in their functional vision that have been observed.
Discussing the environment that the patient is often in can be helpful in case of recommendations or modifications that need to be made, such as placement to reduce the impact of glare for your photosensitive patients.
Discussion on mobility as well as device use can be helpful to see how the functional vision is affecting their everyday life.
So as we’re kinda getting started, I wanna pose a scenario for you all. So we’re getting started with the examination, your patients, rather upset and we want to think what approaches can be used to help calm them down as we start the examination.
Could this be playing music shows that they are familiar with, starting the examination with games rather than specific tests, conducting the examination in free space rather than in the exam chair, or all of these are potential approaches.
All of these are absolutely approaches and are all very great ways to engage the patient. For those that are very upset or uncertain before entering the exam room, I’ll often ask their family that has come with them if they have any favorite shows or songs they like to listen to. Some patients will be like let’s put on spongebob or a favorite Part-two like Coco Melin or other patients will have little Taylor Swift singing sessions, depending on what they find to be comforting.
Allowing the patient to really explore the room can help them get used to the space rather than just jumping right into the tap. And overwhelming them with not only a new testing area, but new tasks that are might be more in their space than they want to be.
Use sub social stories can be used prior to coming to the examination which shows photos of the different steps and objects that are used in exam. It’s not new for the patient when they arrive.
Other clinics I’ve been at have had images on the wall so the patient can follow wrong at each point of the examination, kinda like a schedule.
At Perkins, during COVID when we were full PPE, the mask, the hair bonnets, the gloves, everything. We would often send the patient’s family photos of us without all of that on. As to try and remind the peole, tell the patients that we are human and not just some aliens and PPE.
A part of a lot of the examination is going to be reliant on some of the injected measurements and observations. That you get during the examination.
This can really start before the examination even begins in the exam room. Oftentimes as I go out and greet my patients, I’ll see you know, facing interested or a little bit more timid? Are this the patient able to walk? Or are they using a cane?
How is their posture? Their gait? Are they bumping into things? As they enter that room, are they visually curious about the space? Or do they kind of hang out in a corner and still not sure about everything that’s going on?
Of course, observations will continue throughout the examination, and this can include things like head turns, tilts, any gaze preferences as these can give ideas for things such as null points for patients with nystagmus.
And then of course use of other symptoms that might not just be visual or in conjunction with the visual system.
So as we start to gain visual measurements, often I’ll prioritize doing both eyes first to get an idea of the functional vision use.
This is also helpful if I think that the patient may fatigue easily.
Testing can be done with alternative materials ranging from your typical letters or number symbols, as well as different shapes, grading cards, or even real objects.
Oftentimes, I’ll often implement matching responses in order to help guide the patient a little bit better.
If I am going in for monocular testing, oftentimes I may use a sticky eye patch so that way the patient doesn’t have to hold it or use tape occlusion on the glasses such as we have pictured here or even just use of the patient’s palm.
Important to make sure that anything that is covering the eye isn’t pressing on the eye itself as that can affect the APA once we go and check the other eye.
We often use patty picks or Leia symbols, both of which use the familiar shapes of circles where parts, and apple, but with just some slight variations in their setup. This can give us resolution acuity which tells us the ability to resolve and identify that object.
This can be done in a crowded line or a crowded card, as well as getting single presentation on the screen or with the playing cards.
You can employ matching like I mentioned earlier, which is great as you can straight up provide the image in front of them for those who may not be able to verbally say the shape that they’re seeing. You can also further simplify the matching in a two force choice paradigm, making the patient have to choose simply between two images to determine which one matches the symbol that is shown.
We, of course, have grading car acuity, which is our detection acuity, which can overestimate SNellin as the patient merely has to determine if an object is there or not.
Rather than having to fully identify it. Picture here, we have teller cards, which of course uses preferential looking with the idea that the Patient will look to the side of the card that the grading is on, rather than the side that has nothing. It has different set distances, as well as norms for the first twenty four months of life.
When you use these cards, you really want to just assess what side the patient looks at Sometimes if I’m not sure how the patient fixates, I’ll start with some of the bigger cards and just show the very gross bars. From there, I can get an idea of the patient takes a while to fixate, is a quick fixator that looks away, or if they need a moment to assess both sides before determining which side their choice is on.
You’ll want to make sure that your fingers are on the edge of the card and not leaning over into the card like it is on the right of this image. As that might draw the patient’s attention and give you a false indication of where to look at the stripes.
You’ll also want to be sure that the examiner doesn’t know the side of that the Jiran, as that can bias the response that they believe they see as far as the eye movements. It’s also important to test each side a couple of times in different directions before checking to see where the stripes are.
Leia paddles such as pictured here are also an opportunity to use. However, again, you as the provider would likely know which one has the stripes and which one does not. However, you can still do things such as determine what ways the grading is going as well as the directions up and down or side to side.
Other approaches for those with poor acuity include using room lights or LED lights for distance in near light perception.
Light perceptions nearly the ability to tell if the light is on or off while light projection indicates that the patient can tell the direction that the light is coming from. It is important to make sure that the device that you’re using doesn’t emit heat. As I’ve had patients who were no light perception, correctly tell me when the light was presented or not presented to them because they were able to feel the heat of the light on their cheek. When the transits illuminator was shining on them.
Function acuities are also an option. As we know, visual acuity is simply the test distance over the object size.
I’ve had patients who were not interested in doing teller and would simply look away and were very much driven solely by the toy that they came in with. And at that point we decided to use the toy and place it at different distances without the patient looking. And determine and see if the patient was still able to find it, then took those measurements to see how far away in the exam room they were able to still find their preferred toy. As the visual acuity.
Contrast or the ability to detect more dim and dim images is not often tested in a typical examination but can provide a lot of functional information.
It’s very helpful as far as safety and navigation as well as a lot of reading materials often have a lot lower contrast, such as newspapers.
Poor lighting and only complicates that problem.
Contrast sensitivity tests, of course, include the peli robson for those that are able to do letters pictured here to the right. Workly disc here in the middle is another approach where the patient merely has to mark the squares that have the different circles in them. And then Heidi Heidi uses preferential looking as you see where the patient looks to see if they are looking to a more faint and faint image of the smiling girl.
Dr. Zane and Cran recently developed a double happy test, which also uses preferential looking. As you can see here, the smiley face stays the same size, but we’ll get dimmer and dimmer as we go through the card deck. Just like teller acuities, you simply present the card and see where the patient’s gaze is looking. Here pictured, we have doctor Mayer, one of the creators of the double happy, showing the child the smiley face and he’s correctly looking to the side that it is on.
As a reminder, contrast sensitivity norms are listed here with typically one point six five log contrast being within norms but of course the values are a little bit lower for children who are still developing.
And I will be sure to see about getting these slides to you all so that way you can see some of these resources and other norms that I have here.
Visual field, of course, is the ability to detect objects within our seeing space.
There’s many functional implications for visual field loss. Besides mobility and orientation, it can affect things like visual search. As well as socialization with others as parts of facial expressions, oddity language, and pieces of sign can be obscured.
Regent is also impacted, especially when the blind spots near fixation.
When we think about it functionally for my patients, I often think about where they should perhaps be sitting in a classroom or within group work or where a material should be presented to them in space to allow for maximum accessibility.
I’ll typically test this again with both eyes open and in free space in order to allow for less claustrophobia, and make it a little bit more motivating.
Sometimes I’ll have other family members kinda jump in and help me out to see about having the child sit in their lap or what might make a good fixation target such as a toy or a video. You just want to be sure that whatever you’re using as your fix target isn’t too distracting as to not be aware of any targets that you present onto the sides.
Approach of course conclude our typical finger counting or kinetic finger fields.
Oftentimes, I’ll use a layer wand or a flickering light wand as pictured at the bottom here. And I’ll have one of my interns present the lights from both sides from behind the patient. While I take a look from the front of from the front of the patient to see when they avert their gaze to see where the light’s coming from.
There will still be some patients that you can gauge for more traditional visual field testing such as on the golden perimeter.
It’s really great for plotting both central and peripheral fields, and really allows for frequent breaks and modifications of the approach in order to be a little bit more individualized for your patients, unlike some of our more automatic parameters.
There’s several norms that are included as far as age. But, of course, since we can modify it, we can even test patients who are even younger. I recently had a twenty three month old, where we suspected side vision loss And while this isn’t necessarily a reliable field, we did have the patient sitting in the mother’s lap, looking at a spinning light target in the middle, and every time she was looking to the center, we would flash the light to the side and make a marking when she did avert her gaze. Giving us grossly full side vision.
Other primary tests perimetry tests exist that use gaze aversion often using a video eye gaze target, as well as peripheral lights to help quantify pediatric patients.
As we move into refraction, retinoscopy is going to be your best friend.
Oftentimes, the use I’m relying on the cycloplegic retinoscopy in order to determine the glasses prescription.
Your testing can also take place to determine the refractive error, such as the Mahindra technique, which is done in a dark room, what? Fifty centimeters and subtracting one point two five diopters from your final retinoscopy to get the final RX.
You can also use the monocular estimate estimation method or MEM to assess for the accuracy of the accommodative system, as we know that some of these patients may have a more impacted accommodative system than others.
While the ideal target is, of course, one that you can accommodate to, we want to make sure that it’s one that is interesting for the patient as well.
Once I had patient who had about a plus two five lag of accommodation using our traditional Emmy of Symbl card. However, his mother was like, I don’t think he’s really looking at your symbols. How about you use one of his favorite toys instead?
And while it might not have been the most appropriate target, He certainly, behaviorally, began to engage more with the Target and toy once we used it. And we saw that his lack of accommodation disappeared and was within norms. So it’s important to make sure that while doing the test appropriately might be important you want to make sure that is again meaningful for the patient so the data that you’re getting is accurate.
Doing all of these tests within free space is going to be important. This will be use of trial frames or loose lenses instead of using the lens or retinoscopy rack.
Often, this really helps reduce that feeling of claustrophobia and makes the patient feel a little bit more relaxed.
Finally, if I do find a change depending on the patient’s level of cognition, I might ask if they notice a subjective difference in the room or what they’re watching on the television through the trial frame or withholding the lenses over. If the patient says, yeah, I think there is a little bit of an improvement. We can go back and test the Quity to see if there is a measurable one and make our decision on the prescription from there.
For motilities, it’s important to have an interesting target. Most of us often I’m using spinning light toys, as pictured here. However, you’ll want to check-in with the caregivers to ensure that’s not a trigger to the patient for seizures or other things.
Other options of course can be following a phone as it moves or a tablet playing a video, and sometimes I’ll even pull out a mirror and test the patient that way.
From the mirror, I’m also able to get some functional vision information such as patient’s attention, fixation, as well as interest level in looking at humans. And even the ability to recognize themselves.
Color vision can be assessed a number of ways. Formally, I often use the wagner color vision made easy, which is pictured here in the center, which is a pseudo isobocratic color vision test that is employable for patients up to an acuity of twenty two hundred. What’s really nice about this one is that every page has a circle one of the shapes and in the office we use the wooden circle toy pictured here and give it to the patient and have them match it to the big circle. This allows us to be able to assess color vision formally.
Of course, if those approaches don’t work, you can always assess color awareness.
Such as with the colored chips and matching them to be the same color.
For my patients that may have lower acuity’s, I’ll pull out a light box and use some translucent chips pictured here in order to determine what level of color vision or awareness they have.
Picture here at the bottom we have the PV sixteen which is the low vision version of a D15.
And again we can do color identification through completing a fish puzzle that we have in the office to see if they match the body to the head with the right color, as well as using the caterpillar test and asking about color naming, doing completion of that task.
Alignment can be done in free space without getting up too close to the patient. If the pay if cover test isn’t an option, we can look at the pupil reflex through the Hirschberg method.
Here we see that the left eye pupil reflex is displaced inward suggesting that the left eye is out in exotropia.
Cryncy can then be used to assess the magnitude of the deviation by measuring with Prism to until the two reflexes are aligned to get that magnitude at the turn.
The tuck caterpillar test, as we mentioned on the page previous, can also be used to assess alignment while they stream the chips onto the string, as well as using Brechner to see the pupil reflex and if there’s any inequality in that red reflex.
Debt perception can be tested a number of ways. I enjoy using the pass test pictured here, which is a forced choice test, giving with one blank card and one card with a smiley face. That has to be — that can only be seen through the use of the polarised glasses, making a global stereo test.
The child will then kind of decide between the two cards, which you can see either through gaze or the patient pointing and verbalizing.
Which can be great to assess the level of depth perception presence. I’ll also have local tests such as the random dot three or stereo fly, which has more monocular cues. And then for those patients that polarized glasses wear isn’t an option, we have the laying test, which is going to be the only one that doesn’t use glasses.
Testing of Cades and pursuits can be helpful as ocular motor and binocular vision problems can arise within this patient population.
Insucco testing of the case and pursuits can easily be modified For SUKADE testing, I’ll often ask the patient, where instead I won’t even ask the patient, I’ll have two Light Toys, and I’ll see how they shift their gaze as I turn one light on and off to the other.
Often times, all assess pursuits while doing motilities as to not tire out the patient and reduce the number of tests that we’re doing all at once.
For those that are able, the developmental eye movement test or DEM pictured here, as well as the team debit can provide more information on psychotic dysfunction.
As we move into the health assessment, it’ll be important to maintain as much free space as possible. This means using handheld portable equipment, which will be important as it’s less intimidating and can also be used elsewhere in the room and not just in the exam chair. Sometimes I’ll have my patients sitting at a small kids table we have in our office or laying on a couch or a mat that we have in the room as well. And then we’ll test them wherever they’re at in a way that’s comfortable for them.
For externals, we’ll often use a handheld slit lamp or more often, a high powered magnifier with white and black lights. This allows us to move around the room a little bit more and is a lot less terrifying to the patients than having to sit in a more claustrophobic slit lamp.
Intraocular pressures is often best done with eye care or tonal pin or other free space device.
I’ll always talk my patients through what’s going on and what’s going to happen, including any lights or sounds or sensations they may experience.
Often times I’ll call my eye care, the tickle machine from how it brushes against the eyelashes, which can startle some patients if they’re not looking forward to it. Of course, palpation is an option as well. And oftentimes, I’ll play boot, boop, boop on their foreheads before going for their eyes as to acclimate them to it a little bit better.
Let’s check the dilated health exam will be through binocular and direct ophthalmic.
When dilating, oftentimes, I recommend using a combination drop, which might be the best approach to get as much dilation in there. For the older patients, I’ll kind of discuss within the options of using a numbing drop beforehand, and let them decide if they would rather more drops that with less sensation or less drops with more sensation.
Other times, I’ll instill the drops by having them close their eyes and simply instill the drops into their inner caruncle and have them blink it in.
For patients with motor difficulties, oftentimes I’ll recommend the eye drop squeezer. We have an image of one such here. Which can be helpful in reducing the amount of pressure needed in order to get those drops out of the bottle.
After instilling the eye drops, they always occlude the pump does. As we’ve seen many of our patients can have a number of other diagnoses. And we want to ensure that the systemic absorption is as minimal as possible.
Often times I may do BIO through using a video or a light toy to kind of direct the gaze. Or other times, I’ll just have the patient watch the TV and I’ll move around them to get the views that I need.
If I know that it’s going to be a limited the limited examination, definitely I will prioritize the posterior poll in order to get the most important view in and give myself the most information.
What I also find to be really important in all of this examination is documentation.
I don’t always get out to the far periphery and sometimes my view optic nerve is simply it’s sailing by my view for half a second, and that’s the best view I’m able to get. It’s important to note that if your views were fleeting or, you know, any limitations that you might have had in the examination, as well as anything that was helpful, such as any specific shows or toys that the patient really enjoyed that helped them increase their engagement.
General modifications overall just include really meeting the patient where they’re at. For those that are a little bit more tactile defensive, you’ll want to consider starting with test that are outside of their personal space, things like acuity or motility or just observing alignment, rather than getting right in in person early on.
Giving frequent breaks is very important. And while that time may be used to play or listen to music by the patient, observations can still be made by the examiner.
To determine how their vision is being used as well as in conjunction with their other senses.
Modbling tests to patients beforehand can be helpful in doing them prepared for what’s going to happen. This can be done on toys, caregivers, on the examiner, on their hands, etcetera. There’s been many times I’ve given eye drops to a doll before I’ve given eye drops to a child and it can be very helpful as they’ll understand what’s kind of coming for them.
One of the busiest assets I think we have in our exam room is a television all the way across the room. I’ve mentioned several times that we often ask the patients think that they’re interested in watching, and then we’ll put on spongebob or what have you on the TV. And all of a sudden I have a great target to do cover test or have a great distance, rhinoscopy target.
And really gets the patient to engage with something that isn’t looking right at my light when I don’t leave them to be.
I’ll also use the distance target to kind of get in a subjective idea of any changes in prescription that we found. By asking if they feel like their favorite show looks any better through the new prescription.
For those with multi sensory impairments, it will of course remain important to continue to collaborate with the caregiver unapproaches to communication.
Oftentimes, I’ll continue to narrate what I’m doing with the patient as well as ask for interpretation as needed.
A lot of these patients may need more acclimation for touch as they don’t have visual or auditory sensation that it will be coming for them. This can be starting with kind of hand holding and rubbing the patient’s hand to let them know you’re there. And then slowly I get them used to having them feel my hand again my face and that can kind of help them get used to me kind of working around them when I’m doing BIO or looking at the health of their eye.
Tactile approaches within demonstrations as well as explanations can be helpful for the participation. And again, I really recommend speaking to the caregivers.
Better with the the patients.
As we’re kind of wrapping up the examination, we’ll wanna make sure that we see what the initial concerns were from the patient and their team and address them.
Families are really going to be wanting information on the functional vision. And how it can help their patient at the home, at school or elsewhere that they’re at in their day to day lives.
You’ll want to make connections on how we change testing approaches in the environment, and how that can be adaptive to modifications that can be made elsewhere.
For instance, patients who were like sensitive to the exam room and needed everything conducted in the dark, we’ll want to make sure that we recommend they sit away from banks of light. And that their backs are facing to windows or other glare sources.
For patients with visual field loss will provide prescriptions of the best places to present materials.
And for those who have light perception acuity or low contrast, we’ll make connections and recommendations to using high contrast materials or even use of high contrast clothing, makeup, or name tags to help with patients identifying people around them.
You’ll definitely want to make sure that you’re clear about the follow-up to your clinic as well as making sure that they’re being in with the other care that they have elsewhere.
Oftentimes you might be collaborating with other providers not only vision care, but those on the educational or rehabilitation team, such as teachers persons with visual impairments, orientation and mobility specialists, occupational therapist, physical therapist, what have you?
It’s really important that all of these team members kind of talk with each other in our in communication well as sharing the outcomes of their assessments with each other.
Sometimes we may discover changes to visual function, or implications that can be made to the other therapies that they’re having, and we’ll want to make sure that the way things are presented to the patient is consistent across the different therapies, so they’re able to maximally engage and take part in something that’s accessible to them.
Finally, the reports generated from the examination outlining the findings as well as implications for visual functions should be made.
You’ll want to make sure that your recommendations are in plain language, as it may be shared with those who are not as savvy with eye care world or work as closely with eye care professionals.
Alright. So winding down, I have a true false question for you all.
True or false There’s no need to provide glasses prescription if you do not think that the patient would wear it.
So the majority is going with false.
And for me, that is the correct answer. So as far as glasses, if we find a need for them, specific refractive areas, concern for amblyopia, a near ad, we should provide the prescription even if we’re not sure if that the patient will use it.
Not only can it provide clarity in acuity and vision, but it can be protective to the eyes as well.
Of course, patients can be tactile defensive, and we’ll consider things such as desensitization programs.
Which is taking steps in order to get patients to tolerate things a little bit better, such as glasses wear, or use of eye drops or what have you. When I talk to those who do decent work with some of my patients, they talk about just getting some sunglasses, having the patient hold them, having them accept it touching them, slowly working on to having the sunglasses touch their face. Wear of the sunglasses and then transitioning to day to day glasses.
Similar things with eye drops such as practicing first on a toy, then on the patient’s skin, then on their cheek or forehead, and then slowly getting to the eyes.
Often times this can help the patients accept glasses wear a little bit more which can continue to go on throughout their life.
When getting glasses, it’s going to be important that the patient is there, so the frames fit and that they are of a style that they enjoy.
You wanna consider use of a strap to keep the glasses frames on a little bit better. As well as use of flexible and durable frames, especially for those who might be more likely to take them off and toss them or chew on them or just lose them.
For those patients that are in need of devices, low vision or otherwise, you know, the patient’s developmentally ready to be provided. And oftentimes you’ll want to connect it to something that the patient’s interested in, and not necessarily something specific for school or their vocation.
This could be using a monocular telescope to bird watch or a dome magnifier to look at comic books or other things that are interesting for the patient. It’ll be important that they have support at home and school to continue facilitating and improving their use of the device.
These days you have a lot of questions regarding optical versus electronic devices.
For optical approaches, I’ll often think about any motor difficulties that the patient might have, and that will determine if I’m gonna give a standard handheld magnetic magnifier or if I’m going to use something that has a stand like a stand magnifier.
For our electronic approaches, there’s often a lot more customization that you can have such as changing the font size, the text, changing contrast options, screen brightness, so many things. As well as having access to speech to text.
Many options as well as many, excuse me. Apparently, a lot of the alternative and augmentative communication devices or AACs that a lot of our patients may use are now on iPads. So when my patients come in with any type of communication device, all kind of measure the images that they have, see how the spacing looks, the contrast of the icons that they’re using. And if I have any findings in my examination that suggests that perhaps they can’t see the size of the icons or the contrast isn’t high enough, we can make those recommendations to their team members to explore a little bit more in order to make sure that the device remains accessible for them.
Since we wrap up, I have a few different resources that helped me kind of put this together.
Of course, the special Olympics is an incredible organization that provides a lot of healthcare opportunities to individuals with disabilities.
As a part of their program, they provide health screenings not only for the eyes, but for several different systems.
The special Olympics finds that about two in ten athletes in a special Olympics team have never had an eye exam. And that four in a tenor in need for a new prescription for glasses.
Oftentimes, the special Olympics will link up and try to facilitate some of this in order to get access to healthcare and eye care for these team members.
For those patients that are still within the educational system, I’ll often direct them to Perkins’s expanded core curriculum.
It involves a number of life areas, from compensatory skills, assistive technology, self determination, and career and education, which allows for a more positive transition into the community once the patient graduates, as well as teaching them self advocacy skills.
The American foundation for the blind provides a lot of career guidance research and advocacy for individuals with disabilities.
The World Institute on Disabilities has several sources on accessible design of healthcare systems, community inclusion, as well as career and financial planning.
The Center for Disease Control also provides a great disability inclusion resource that is about overcoming barriers. Similar to the ones that we discussed at the start of this lecture.
For those with children, I often recommend the book here at the bottom.
As it provides guidance for parents through the educational planning process at all points of the educational system.
A few advocacy resources I recommend include special books by special kids, which has a social media presence, as well as Internet, website, that’s really sharing stories of individuals with various conditions and disabilities. In their day to day lives.
Positive exposure is an organization promoting inclusion and fashion photography.
Shown here is their special in a nineteen ninety eight issue of Time magazine, highlighting individuals with albinism.
I really find these resources great as you can hear in the words of potentially our patients, some of what they experience day to day, and how we can better support them.
Some of my final resources include the ten commandments of communicating with individuals with disabilities.
Of course, the cyber site website has a great series of videos on caring for patients with disabilities that goes into more depth on a lot of topics that we touched on here. Such as refraction, eye care examination, surgery and other considerations.
CBI Scotland provides a great overview of cerebral visual impairment, which is the leading cause of pediatric visual impairment in developed countries, as well as providing several suggestions for modifications that can be made for these patients.
And then finally, some of the texts I often refer to as I was making this lecture.
So as we wrap on up here I have a singular question and would just love to see how everyone is feeling now as far as comfort and giving care to individuals with disabilities.
I’m glad to see we’re filling overall more positive after this.
Well, thank you to everyone who came in this morning. I’m happy to take questions in the Q and A.
All righty, so the first question I see here is any special consideration for cycloplegic drops in patients with disabilities.
Often times, I’ll definitely consider those who have cardiac concerns or any of our other standard contraindications regarding cycloplegia in our patients. Of course, there’s a lot of concern with patients who have down syndrome or trisomy twenty one in their ability to take cycloplegic drops. Typically in this instance, a lot of my patients are co managed with other providers. And if they have previously in the past, done a cycloplegic dilated examination without any adverse effects, I’ll feel more comfortable also doing a cycle examination.
However, if I don’t have any documentation there, or of course there’s any contraindications, I’ll continue use of tropicamide or other weaker use of drops.
Another question is how would you assess vision, refraction, and elderly patients with hearing disabilities?
For these patients, oftentimes, I’ll again rely on a more tactile approach. Something that I found to be helpful, especially with refraction is when doing one or two to tap on the patient’s arm one or two, and then do the change of course at the same time. And kind of doing a refraction that way.
Sometimes having yes or no answers or questions can be more helpful when working with patients when hearing impairments, as well as seeing if they have any other alternative communication devices and styles that they use.
Another question is regarding giving the patient glasses when they were born with an ocular condition.
It definitely kind of depends, though I feel like if the patient’s able to tolerate it and that they’re still preserving vision, wearing glasses will continue to protect the eye from any injury.
You know, there’s some thoughts that should we treat amblyopia or other refractive concerns in patients who have optic nerve concerns like hypoplasia or optic atrophy. And to an extent, I think it is worth giving the glasses prescription especially when they’re within that critical period in order to provide some of those connections to still be made. I think it’s more important to Even if the acuity is never going to be a perfect twenty twenty, excuse me, if you will. I think it’s important to provide the best possible view that one can get and that will include continuing to do glasses care as the patient’s developing visually.
Another question regards EUAs or examinations on there and esthesia.
A lot of these patients, I will, if, you know, it seems like eye drops aren’t going to happen, if it seems like, you know, they’re very tactile defensive. It’s not going to happen. I’m not someone who enjoys pinning down children or by patients at all. And if I don’t think that’s gonna happen, I will refer for an EUA. Definitely, there’s some of my patients where that’s just going to be a much better approach for them.
I’ve gotten a couple of questions regarding mental illness and disability and I think, you know, it definitely falls under a disability category, if you will. A lot of times these, you know, conditions or these diagnoses have significant and back to day to day life that don’t allow them to necessarily partake as one typically would and that in itself is definition of disability.
So you know, definitely can impact different points at the day and different things and say you have a patient that’s particularly anxious. You might need to take a little bit of more time and a little bit more, you know, slower communication style and some of what we about here in order to make them feel more comfortable to help them engage a little bit better.
I have a question here about age limits for optical and non optical devices.
And for me, I don’t think of an age limit per se, but rather where the individual is both developmentally, cognitively and things like that. You know, I’ve had yeah. There are young children who were able to use a monocular quickly and didn’t have any difficulties whereas I’ve had older children who couldn’t figure out how to use a handheld magnifier So really it’s gonna be a little bit in office of seeing how they use it, how comfortable are they and what they can achieve with it. And if I think that there’s some possibilities there. I’ll recommend that their team explores it a little bit more with them.
However, I always think it’s important to make it known that these devices are going to be tools to use and not just toys to play with.
I see a question here about managing visual impairments among prisoners as their vulnerable population.
And I have had some experience working with population as they have come into some of the clinics I have worked in.
And it can definitely be very difficult, especially kind of coordinating with the institution that they’re at and making sure that they make the follow ups, which might not be always possible. So for these, you know, patients that are having a little bit more vulnerability and might not be able to make as many return follow ups, I take a little bit more time with these patients and kind of see multiple different you know, problems that they may be having and try to address as much as possible kind of going in so that way we can try to make sure that we’re maximizing the time that we have together to address as much as we can for them.
So I see a question here about how we can manage children between three and five to wear glasses. And this is definitely that age where my patients start throwing off their glasses and not wanting to wear them.
As I mentioned, kind of use of a strap can be helpful to at least keep it on the head or at least keep it on the body if it does come off.
A lot of times we’ll want to make sure that it’s comfortable for the patient. So I have had a number of people come in and they’re like, oh, child never wears the glasses. It’s not great. And then I look at the glasses. It’s completely smooshed up against their face, pressing the eyelashes into the eye, and no one wants to wear anything like that. So something I always kind of do first is make sure that the fit is comfortable and that’s not brushing up against the eyelashes or pinching the ears or anything like that.
At that point, if we’re still having difficulties, sometimes I recommend my parent, to caregivers, to put the glasses on and immediately provide a toy or something interesting for the patient to look at.
So that way kind of directs their attention away from the glasses that they don’t want to, something that they do enjoy.
Sometimes another thing that I have done or told parents to do is to kind of play the glasses on while the child is asleep so they wake up with the glasses on and might not think about it as much. So those are some strategies that can kind of be used there.
All righty. So I have a question here about discussing with patients children with low vision.
And a lot of times, within within my patient population at least, there’s a lot of you know, they already kind of have their diagnoses and have an idea that their child’s visually impaired. So a lot of times we’re not necessarily discussing, your child is the be word, blind, or visually impaired.
But oftentimes you know, if that is the conversation we have, I always point to, you know, this child is exactly the same child that walked in an hour ago.
You know, while they might have a new label, we give a new diagnosis, or something like that, I always kind of discuss how that can be empowering for the child, how we have answers to perhaps any difficulties that they may have, and that it will also allow them to have access to different resources and support strategies to make sure that they can thrive and, you know, be the best that they can be within their life.
So I really appreciate everyone coming in today. This was a wonderful chance. So I want to thank CyberSite for having me today and if there’s any more I have had my website, sorry, email here on the slide.
So, Hope everyone has a wonderful rest of your day and take care.