Reporting the Findings
Our reports are either for our colleagues on the diagnosis and medical care of the deafblind patient, or for the school, workplace or state and other agencies on the disability of the patient.
The diagnostic work and reporting related to our deafblind patients is similar to any diagnostic work when examining hearing patients. The only exceptions are the few syndromes that include both hearing and visual impairment. An exact diagnosis requires a rather thorough investigation before we can be sure whether the patient has, for example, Usher Type I or Type II. The nature of the retinal disorder is not specific enough when assessed with the present tests and therefore the diagnosis can first be made after combining the results from audiological exams and balance tests with the visual data.
The reports to the schools should answer three important questions: how much vision and what kind of vision is there is for
Presently we have no guidelines on the visual parameters that should be used when deciding on the type of teaching group or individual. The scanning techniques used by deaf persons vary. The capacity to compensate by using short-term memory to fuse the different pieces of visual information together varies as well. The place in the classroom and the type of visual communication also play important roles. The final analysis of functional vision for communication has to be made at the school by an experienced deafblind educator who can measure communication field in the classroom, knows how to observe communication in a group situation and can weigh the advantages and disadvantages of individual teaching as opposed to teaching in a small group.
The second specific question on mobility and orientation is easier to answer. Teaching in orientation should be started as early as possible in all cases of progressive field loss. There are so many things to be learned about the structure of our environment, techniques of transportation, and cues to use when vision becomes worse, that the two or three hours a week that will be available are always well spent. At the same time the teacher and the child learn to know each other and this is important for the time when mobility instruction becomes actual. It is always a sensitive issue because it immediately makes the child and the peers aware of ensuing blindness. These children seldom need the mobility techniques of the blind other than at night. Since the training occurs during the daytime many mobility teachers seem to teach night travelling by blindfolding the child. If the child sees in the dark, it would be better to use dark enough glasses to simulate night vision. The child has to learn to combine the inadequate and often misleading visual information with the tactile information from the cane and/or sonar guide. It is then the ophthalmologist's task to specify the training goggles for training of mobility. Changes in visual field and dark adaptation should be reported to the school each time the child is seen. On the other hand the mobility instructor should report all observations made during training.
The third specific question is related to physical education. A great majority of deaf students with Usher's Syndrome report considerable difficulties playing ball games, years before they have developed absolute scotomas in midperipheral field. Since we have no clinical tests of motion perception which would depict visual functions in tasks typical to tennis, baseball or other ball games, we have to rely on information that we can get from the P.E. teacher. If the child and the teacher have contact with other older children with Usher's Syndrome they learn to observe visual symptoms and make adjustments when needed.
Children with central scotomas are rare and their situation is better understood at school because the loss of central vision can be measured by using the regular visual acuity chart. We must remember to inform the school that the child has tunnel vision whenever he uses a telescope for reading from the blackboard. The telescope for classroom work should be evaluated at school and training should be thorough. Quite often visually impaired children at the schools for the deaf do not receive the same amount of training in the use of visual aids as those children in the schools for the blind. The problems are closely the same although special attention should be given to the effect on communication. The compatibility of visual and auditory aids is a special problem to be remembered as well.
Our ability to give pertinent information on functional vision is quite limited. However, if we work in collaboration with the special educators we can be helpful in making the modifications needed in the curriculum of a visually impaired, deaf child. Even more helpful is this collaboration in assessing the need for consultations in terms of psychological, social or vocational rehabilitation.
Our reports on adult patients should contain basically the same information as that given to the schools. Traditionally, our low vision assessments have been geared toward an analysis of vision for sustained near work, reading and writing. When examining deaf persons who use ASL we must remember that reading may not have the same role as it has in the life of a hearing person. The structure of the work needs to be analyzed with both impairments in mind.
I suggested that the visual functions of each visually impaired patient should be assessed in relation to orientation and mobility, ADL (activities of daily living), communication, and sustained near work. This recommendation is valid in the case of dual sensory impairment, with special emphasis on communication.
As was mentioned earlier in this chapter, our clinical assessment of vision does not give us relevant information on functional vision required in orientation and mobility tasks, ADL or communication. We can measure the communication field and thus inform about restrictions of distance, luminance, and the size of signs used. However, quite often there is an unequivocal change in the receptive skills of a deaf person without a measurable change in the visual parameters that we are used to examining. The need for more specific tests measuring perception of low contrast moving targets is obvious for the assessment of visually impaired, deaf persons.
Once we have written our reports and statements for the different offices, we should remember to ask the patient during his next visit, whether any of the suggestions on rehabilitation have been executed. Since visually impaired, hearing impaired patients do not fit the usual categories of blind or deaf, they are highly likely to be denied services that they really need. The bureaucracy of rehabilitation is often so complicated that many deafblind patients give up their fight for visual aids and rehabilitation services. In some countries there are also unusual restrictions on services to housewives who take care of their children at home. They are not considered workers and are not eligible to all rehabilitation services or even assessment. As physicians we may be able to correct some of the inadequate decisions. Other cases of injustice require our explanation for development of sound legislation related to rehabilitation.