Convergence Insufficiency

I adore my Orientation and Mobility Specialist friends and colleagues, but for all intents and purposes, there is a real good reason why I never trained for this particular profession: I can’t find my way out of a paper bag. And if that’s not bad enough I reach royal status by having the ability to make a wrong turn even using a GPS.

My husband is from the state of Utah, which means he grew up with the coordinate system using strict cardinal directions to get everywhere from point A to B. The whole notion of having an address such as 1638 North 475 East makes me scratch my head in utter confusion. Huh? I grew up where the corn grows tall and if you wanted to know how to find my town’s high school you’d be told to turn at the old NAPA Station (which hasn’t existed in YEARS, but everyone knows where it used to be).

Recently I gave a conference presentation on the topic of why my state needed to begin developing a guidance document on educating students with visual impairment. I purported that having state procedure guidelines would create structure, consistency, consensus, and efficiency of educational services across the state. Without such a “road map” a TVI finding his or her way through educational programming decisions would be similar to two TVIs each told to drive from the east coast to the mountains of North Carolina to find the same student but only given a compass and the direction to head west. The variation of routes could be limitless. But if each TVI were given a compass and road map, structured, consistent, and efficient routes could be drawn.

I think our field of visual impairment started to enter an uncharted territory beginning in 2014. It was in November of 2014 when a federal letter was released to the states explaining that while states were allowed to establish their own standards of eligibility, state established standards could not be more narrow than federal regulations. I can remember reading the letter (11-12-2014 Letter) and holding my breath wondering what the outcome would mean across the nation as it related to serving students with visual impairment. Less than three years later the Office of Special Education Programs issued a memorandum to clarify eligibility policy (5-22-2017 Memorandum). The states then received clarification that because IDEA’s definition of Visual Impairment did not include a modifier, any type of Visual Impairment (regardless of significance or severity) must be included in a state’s definition, even the inclusion of Convergence Insufficiency.

Maybe instead of using the analogy of being in uncharted territory without a map or compass a more realistic illustration would be that of being in the ocean and having huge waves crash over our heads. I think all in our profession paused for a long moment of silence as we grappled with the notion of possibly serving students with 20/20 visual acuities.

Not unlike other states, North Carolina’s eligibility criteria included the following modifiers:

• A visual acuity between 20/70 and 20/200 in the better eye after correction…
• A visual acuity of 20/200 or less in the better eye after correction or a peripheral field… no greater than 20 degrees…

A technical change brought before the State Board of Education in November 2017 quickly rectified our case of noncompliance. As mentioned before, my state is now in perfect harmony with federal regulations. But what isn’t harmonizing are sounds of fear and anxiety echoing from teachers of students with visual impairment.

My purpose of this commentary is to demonstrate that by using a compass and map of facts relating to visual impairment, we can all reach educational destinations for all students with visual impairment; even those with Convergence Insufficiency.

Although we’ve talked so much about what has changed, it’s important to point out what hasn’t changed. Teacher preparation programs teach about the three categories of Visual Impairment: (1) Ocular visual impairment (involving the eye, optic nerve, and optic chiasm), (2) Cerebral/Cortical visual impairment (involving damage or disorder of the visual pathways behind the optic chiasam), and (3) Visual difficulties related to ocular motor dysfunction (visual fixation or tracking problems, ocular misalignment, and impairment of accommodation). These categories of Visual Impairment have also been included in a variety of published resources.

What also hasn’t changed is the fact that Teachers of Students with Visual Impairment continue to meet student unique needs through accommodations, modifications, and/or Specially Designed Instruction following a comprehensive evaluation process (e.g., Functional Vision Assessment, Learning Media Assessment, and Expanded Core Curriculum Assessment).

The good news is that now a student with a visual impairment who has visual acuities better than 20/70 may be eligible in the disability category of Visual Impairment, including blindness in North Carolina. In addition, if a child has Cortical/Cerebral Visual Impairment with perfect acuties he/she may now be eligible in the disability category of Visual Impairment.

But now it’s time to get real and address the elephant in the room.

Picture description: Clipart drawing of an elephant with the words “Convergence Insufficiency” scripted on its body.

I think it’s most important at this juncture to offer the gentle reminder that a diagnosis alone should never determine eligibility. It’s only through a careful and comprehensive evaluation process by an IEP team that eligibility decisions are made. And now this means that Teachers of Students with Visual Impairment must consider how vision evaluations can be tailored for students with ocular motor difficulties (e.g., Convergence Insufficiency).

In North Carolina, in order for a student to be eligible in the category of visual impairment, the visual impairment must have an adverse effect and require Specially Designed Instruction. While the term adverse effect isn’t formally defined in IDEA, we teachers use our evaluations to measure the extent of adverse effect.

Possible Adverse Effects might include (but not limited to):

• Ocular Visual Impairment : Decreased visual acuity, Contrast sensitivity, Photophobia, Issues with glare, Visual field loss, Depth perception difficulties, Ocular motor difficulties
• Neurological Visual Impairment: Decreased visual acuity, Visual field loss, Contrast sensitivity, Ocular motor difficulties, Absence of visual guided movement, Difficulties with visual complexity, Need for light, Color preference
• Ocular Motor Visual Impairment: Double vision, Headaches, Difficulty tracking lines of print, Visual fatigue

Sometimes a visual impairment only has an Adverse Effect and in those cases a Section 504 Plan might be explored if the child has no other disability.

Accommodations that may address Adverse Effect might include (but not limited to):

• Visual breaks
• Use of slant board
• Well spaced materials (double-spaced)
• Use of reading marker
• Sans serif font
• Minimize visual clutter on a page
• Large print

When Adverse Effect does require Specially Designed Instruction for students with visual impairment, skills of the Expanded Core Curriculum are taught. Some possible examples include:

• Braille instruction to access literacy
• Training to use low vision devices for visual efficiency
• Instruction in assistive technology to use magnification &/or screen reading software
• Cane and street crossing instruction for orientation & mobility
• Time management, organization, money management, & personal care for independent living skills
• Body language and social etiquette instruction for social interactions skills
• Learning how to participate in health, fitness, and sports activities for recreation & leisure
• Organizational skills and positive work habits for career education
• Assertiveness, self-advocacy, & empowerment for self-determination skills

But what does all this mean when working with a student who has Convergence Insufficiency?

Knowing that this condition is when the eyes are unable to work together when looking at nearby objects because of misalignment of eye muscles, it’s important for our comprehensive evaluations to hone in on specific aspects of visual functioning.

When completing a Functional Vision Assessment a Teacher of Students with Visual Impairment should consider the following:

• Stereopsis
• Near vision acuity as it relates to accommodation
• Spatial skills as it relates to visual perception
  • Visual closure
  • Visual discrimination
  • Visual memory
  • Figure Ground
  • Form consistency

I know there is controversy about whether or not testing visual perception skills falls within the scope of the FVA evaluation process. But I plead for you to consider that over 60% of the brain is responsible for processing visual information. And isn’t all information collected good information if it means better understanding of the student?

When completing a Learning Media Assessment a Teacher of Students with Visual Impairment should consider the following:

• Serif vs. sans-serif fonts
• Size of print for near acuity tasks
• Copying, eye-hand coordination
• Reading stamina
• Listening skills

And although most educators typically only discuss accommodations for students with Convergence Insufficiency, we must be open minded to what Specially Designed Instruction might look like for students with ocular motor difficulties.

• If a student experiences visual fatigue and has poor eye-hand coordination for writing during copying activities, perhaps the student can gain keyboarding skills.
• If a student has near acuity vision difficulties as it relates to vision accommodation, perhaps the student might benefit from using screen magnification software while on the computer.
• If the student experiences severe visual fatigue when reading, perhaps the student might benefit from learning to access audio accessible materials from Bookshare.
• If the student experiences headaches and visual fatigue during copying activities, perhaps the student benefits from activities in the book Learning to Listen/Listening to Learn by Barclay (AFB Press).

In closing, we may be marching through uncharted territory together, wading through the outcome of defining new standards of eligibility, but it doesn’t mean we have to do it alone without the help of a map and compass to guide our steps.