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  • By: Galton Vasconcelos, MD; Luciene C. Fernandes, MD
    Low Vision

    Introduction

    The World Health Organization (WHO) defines a low-vision child as "a child who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 20/60 (6/18) to light perception, or a visual field of less than 10 degree from the point of fixation, but who uses, or is potentially able to use, vision for planning and/or execution of a task."1

    According to the WHO (1992), visual impairment in general affects 4 main functional areas:1

    • Orientation and mobility
    • Communication
    • Activities of daily life (ADL)
    • Sustained near-vision tasks

    During any assessment of a child with visual impairment and other disabilities a team of professionals from several disciplines is recommended.1–5 Generally team members include the child's family members, ophthalmologists, pediatricians, neurologists, optometrists, orthoptists, educators, psychologists, speech-language pathologists, social workers, physical and occupational therapists, and nurses.1,6

    A multiprofessional team aims at

    • Promoting the psychomotor, sensory, affective, and social development of the child
    • Enabling maximum use of residual vision
    • Prescribing low-vision devices and promote proper use
    • Creating and developing strategies to encourage the inclusion of children with visual impairment in family, school, and community

    Team models

    There are 3 models of low-vision services in early intervention and habilitation/rehabilitation programs:3,4

    Multidisciplinary

    Multidisciplinary team approaches use the skills and experience of individuals from different disciplines, with each discipline approaching the patient from their own perspective. Team members work independently and interact formally. There is no planned sharing or overlap in assessment or intervention procedures among the various disciplines (Figure 1).6

    Through this model, family members can express their observations, opinions, and concerns with each evaluator and hear each professional's perspective. However, the various evaluation reports can result in conflicting and contradictory treatment recommendations.6

    The major disadvantage of this model is that it addresses each individual impairment separately, tending to lose sight of how these impairments affect the individual as a whole.6

    Team members
    ↓↓↓
    Child

    Figure 1. Multidisciplinary model.

    Interdisciplinary

    Interdisciplinary teams combine the skills and experience of individuals from different disciplines into a single consultation. The results of the evaluation are discussed, interventions are planned jointly, and each service provider implements discipline-specific interventions.3,6 History taking, assessment, diagnosis, intervention, and short- and long-term management goals are conducted by the team together with the patient and family members. In this model, for example, an ophthalmologist can participate in motor activities planning and discuss pros and cons with the other professionals involved (Figure 2).6

    Interdisciplinary teams have some advantages over multidisciplinary, the most obvious being the patient-centered approach. Furthermore, it provides a stimulating work environment in which staff can learn about and even conduct some of the assessments and interventions traditionally carried out by other disciplines. One of the unexpected advantages of interdisciplinary teams can be the evolution of new workforce roles, developed through identification of service-system gaps not always apparent in multidisciplinary teams.3,6

    Team members

    Discussion

    Intervention plan

    Child (Family)

    Figure 2. Interdisciplinary model.

    Transdisciplinary

    The transdisciplinary model is fundamentally different from the multidisciplinary and interdisciplinary approaches. Here families are active members of the team and interventions are integrated into the daily routines.3,6

    This process can be established by formulating ground rules for the process and maintaining communication among team members by sharing reports, resources, and progress.3 Because the assessment process is collaborative and integrated, service planning and implementation tends to be cohesive as well.6

    The transdisciplinary approach is particularly useful and recommended for infants and toddlers (birth to 3) in early intervention programs, particularly by working with and supporting caregivers and families.3,4

    There are a variety of team models. The role of a multiprofessional team varies from state to state and between different levels of care. Low-vision services are practiced in hospitals, community centers for the visually impaired, ophthalmology centers for the visually impaired, health centers, educational facilities, preschool programs, and in the home.1 The teams can be conducted by a pediatric ophthalmologist, or depending on the local characteristics, by other professionals.

    It is very important that the professionals interact frequently to discuss the various aspects of rehabilitation process. This can be achieved by weekly or monthly meetings in which all team members give their opinion about a specific patient or situation and interventions are planned.

    Vision rehabilitation for children with low vision and their families is an essential component of ophthalmic care. The community, family, educators, and therapists are all part of a team. This can also include community health nurses, social workers and case managers, occupational therapists to assist with feeding issues and fine motor development, physical therapists for mobility, TVIs, early-childhood special-education teachers, and orientation and mobility instructors.2 (See American Academy of Ophthalmology. Preferred Practice Pattern guidelines. Vision Rehabilitation PPP – 2013.)

    At the secondary level, the team can include ophthalmologists; refractionists; and ophthalmic clinical officers, technicians, and nurses.5

    At the tertiary level or teaching hospital, a team of trained professionals provides care that involves assessment of visual function, refraction, prescription and use of full-range optical and electronic devices, multidisciplinary rehabilitation, and training in visual skills and mobility, including orientation and mobility training.5

    References

    1. World Health Organization. Programme for the Prevention of Blindness: Management of low vision in children. Report of a WHO Consultation. Bangkok. 1992.
    2. WHO/PBL/93.27.
    3. American Academy of Ophthalmology . Preferred Practice Pattern guidelines. Vision Rehabilitation PPP – 2013.
    4. Chen D. Essential Elements in Early Intervention: visual impairment and multiple disabilities. New York: AFB press. 1999. 55103.
    5. Hyvarinen L, Jacob N. What and How Does This Child See? Helsinki, Finland: Vistest Ltd. 2011. 179194.
    6. van Dijk K. Low vision care: who can help? Community Eye Health. 2012;25(77):1415.
    7. Jessup R L. Interdisciplinary versus multidisciplinary care teams: do we understand the difference? Australian Health Review. 2007; 31 (3): 330331.