Courtesy of Enhanced Vision Systems

The idea that all low vision patients are the elderly could not be further from the truth. While it is true that many low vision patients suffer age-related macular degeneration and other diseases common to older people, low vision is very fair-minded. Low vision practitioners report that a good deal of their patients are indeed children.

With the advancements in prenatal care, retinopathy of prematurity is reclining, but, it is still the primary cause of low vision in kids. Optic nerve atrophy is second, followed by congenital nystagmus or albinism. They may experience vision impairment secondary to congenital cataracts, inherited retinal disorders, and congenital glaucoma, according to Joseph Maino, O.D., chief of VICTORS Low Vision Center at the Kansas City (Miss.) VA Hospital.

"Children differ from geriatric low vision patients in that they are just learning to read and their accommodation systems are still intact," Maino says.

Melissa Chun, O.D., Vision Rehabilitation Director at the Jules Stein Eye Institute in Los Angeles, agrees. "Children with low vision are quite adaptable, compared with the elderly, because they know what they can and cannot do with their visual impairment." She finds that children want very portable, yet durable devices so they can take them to school or out for hobbies.

"The sad thing is that most child we see do not have the tools to adapt to their low vision. But with a visual rehabilitation program, they can get the appropriate tools," says Tracy Williams, O.D., executive director of the Diecke Center for Visual Rehabilitation in suburban Chicago. For instance, "When a low vision child goes to the zoo and can use a 4x hand-held magnifier to see the animals, you know you have improved his quality of life and enabled him to be independent."

Thomas Porter, O.D., director of Low Vision Services, St. Louis University School of Medicine's Department of Ophthalmology and an adjunct professor at the University of Missouri-St. Louis College of Optometry, agrees that children suffer from the same kind of lack of visual resources as many elderly patients. He remembers a child with Staargarts who learned Braille unnecessarily, before he saw Porter and was told about low vision devices. "His parents asked me, 'Why didn't my other doctor tell me about this specialty?'" he says.

"It is easier to work with younger people who never had good vision or didn't lose it like seniors," says Porter, who adds, "The biggest challenge is getting teenaged patients into devices because appearance is such a major concern."

Maino agrees, and adds that in his experience, the most difficult low vision patient isn't the octogenarian, but rather the vision impaired teenager who wants to get his first driver's license. "Teenagers all want to drive, but they don't want to look different from their peers, so they are reluctant to use special low vision devices such as light filters or bioptic telescopes," he says.

THE EXAM

Williams, who is also chairman of the AOA's Low Vision Section, explains that while examining a young low vision patient, he has the parent observe from behind the child to see how the child sees. If possible, he has the child's special education teachers observe the exam, too.

And, if the low vision patient also suffers from multiple disabilities, low vision optometrist Kathy Fraser Freeman suggests having the child's physical and speech therapists witness the examination as well. "You have to educate each of these people about how the patient's functioning and vision will change with the low vision devices and what type of follow-up care will be required," she explains.

Paul Freeman's low vision pediatric exam includes testing with different visual acuity charts, working distances, accommodative ability, print size, and educational concerns.

In the low vision exam, these patients need a visual fields assessment, either by gross confrontations or Goldmann perimetry. He suggests doctors do color vision testing on low vision children as young as 3 years old, as these tests will provide information about photophobia and optic atrophy.

THE DEVICES

"You can start with a hand-held stand magnifier, prisms and full-view or monocular telescopes without a big investment," suggests Chun. She says there are similarities between a first-time contact lens wearer and a first-time low vision device. "The first step is to talk about how low vision optics differ from conventional optics in their ability to magnify and enhance contrast," she says.

"Sometimes low vision aids are simple where you have to control glare and increase contrast when there is a loss of contrast sensitivity," says Porter.
"I prescribe a lot of FT35 bifocals, +5.00 adds and some contact lenses," points out Kathy Freeman.

High tech devices have added a new, exciting twist to helping young low vision patients. Devices like video sets for older children and, even for the youngest kids, large computer screens with enhancement software, font sizes up to 16x, voice output, and printing capabilities are helping these patients function more independently.

The key to successfully dispensing low vision aids, particularly to young patients, says Porter, is to think of every low vision device as a tool that the patient will use to function better in life.

"We cannot fix the problem," Porter concludes, "but we can teach the patient how to use what he has more effectively." EB