Reading rehabilitation for individuals with low vision

Recommendation The need for further development of special education and rehabilitation of viduals with low vision was stressed as the pivotal conclusion of 2001 international conferen

Reading

Rehabilitation for Individuals with

Low Vision

Research and Practice in the

Czech Republic

Reading Rehabilitation for Individuals with Low Vision

Kamila Růžičková

Reading Rehabilitation

for Individuals

with Low Vision

Research and Practice in the Czech Republic

ISBN 978-3-319-43652-4 ISBN 978-3-319-43653-1 (eBook)

DOI 10.1007/978-3-319-43653-1

Library of Congress Control Number: 2016948728

© Springer International Publishing Switzerland 2016

This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed

The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use

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or omissions that may have been made

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Kamila Růžičková

Dept Special Education and Speech Therapy

University of Hradec Králové

Hradec Králové , Czech Republic

Advisors

Prof PhDr PaedDr Miloň Potměšil, Ph.D.

Doc Lea Květoňová, Ph.D.

Doc PaedDr Jana Lopúchová, Ph.D.

617 – Orthopaedics Surgery Ophthalmology [14]

364-1/-7 – Social Care and Services

Foreword

The development of vision rehabilitation, including reading skills, is a constant ject of interest to specialists, and the author of this publication has been dealing with the issue for many years

The content of the book is the result of a well-prepared concept Due to the fact that the book is intended for professionals, the author considers the factor of development and discusses the dynamics of individual segments of the concept The book includes chapters on visual perception and its defects, psychosocial aspects of visual impair-ment in the context of the age of their bearers and the status of the issue at the national level Most importantly, the book contributes knowledge about the development and innovation of a rehabilitation programme with the use of modern theoretical, assistive and technical means The author’s original scientifi c contribution consists of the cre-ation of an innovative rehabilitation programme for individuals with low vision along with the research behind the programme The results of the research provide verifi ca-tion data of the effectiveness of this experimental programme

The client-oriented approach to individuals with low vision, i.e rehabilitation with the aim of developing functional vision and reading skills, has become not only a support for special education facilities but also an important activity for workers in social and other services To understand the basic principles, objectives and methodology of vision rehabilitation, the author works in a broad interdisciplin-ary context, thus making the publication useful for professionals outside the fi eld of special education

Palacky University in Olomouc, Czech Republic Miloň Potměšil January 20, 2016

Pref ace

Care, education and rehabilitation have a long tradition in the lands of Bohemia and Moravia, parts of the present Czech Republic Current development has been sub-stantially infl uenced by it Signifi cant changes in Czech special education were made possible by the change of political system in 1989 This date initiated a new period of development Twenty-fi ve years of development have shown that the level

of the Czech system of social and rehabilitation services for adults with visual impairment is in many areas comparable with other developed countries In a few selected areas, however, it is necessary to continue to work on development and to achieve global standards of rehabilitation One of these areas is rehabilitation of individuals with low vision

The need to review the current state of knowledge is suggested and evidenced by

a number of important Czech authors (e.g Jesenský, Moravcová, Růžičková, Skalická, Vítková) The author uses in her work numerous foreign professional works which highlight the need for a comprehensive, multidisciplinary- conceived rehabilitation intervention focused on the special needs of adults (e.g Lueck, Silvestrone, Lang, Rosenthal, Faye et al.)

The publication answers a number of questions concerning functional impact of vision rehabilitation on the increase of functional visual performance of adults with low vision The results of the research confi rmed the high importance of the experi-mental rehabilitation programme in all its components ( reading rate , reading accu-racy and reading comprehension) as well as in the monitored intervening variables (visual acuity , age, level of reading experience and activity)

Implemented interventions represented a signifi cant potential for the solution of one of the most acute areas of rehabilitation objectives: they signifi cantly affected the quality of life of the research group Based on the achieved data, the author proposes areas and means for a modernization of the programme of vision rehabili-tation which represent a potential for increase in the quality and effectiveness of the programme

The publication is intended for professionals, especially special teachers or cation assistants, social and rehabilitation workers The author hopes that it will become a stimulus for professional discussions and an improvement of rehabilita-tion services for persons with low vision

Recommendation

The need for further development of special education and rehabilitation of viduals with low vision was stressed as the pivotal conclusion of 2001 international conference ‘Edukace a rehabilitace zrakově postižených na prahu nového milénia’

indi-( Education and Rehabilitation of Persons with Low Vision at the Threshold of the New Millennium ) in the Czech Republic

The topic of development of a rehabilitation programme for individuals with low vision was recommended by the Czech prominent specialist Prof Ján Jesenský, CSc (Charles University in Prague) The interdisciplinary research study was approved by the Ethics Committee of the University Hospital in Hradec Kralove Both the University of Hradec Králové and Rehabilitation Centre for Individuals with Visual Impairment in the Czech Republic participated in the research

Hradec Králové, Czech Republic Kamila Růžičková

Preface

Acknowledgements

Acknowledgements for the collaboration go to the colleagues Ján Jesenský and Lea Květoňová (Charles University in Prague, The Czech Republic), Miloň Potměšil (Palacky University in Olomouc, The Czech Republic), Jana Lopuchová (Komensky University in Bratislava, The Slovak Republic) and colleagues from the Rehabilitation Centre for Individuals with Visual Impairment in the Czech Republic Acknowledgements also go to all people with low vision who were participating in the research Signifi cant assistance was also provided by the University of Hradec Králové (The Czech Republic)

Contents

1 Visual Impairment and Its Impact on Development 1

1.1 Basic Terminology and Defi nitions in Vision Rehabilitation 2

1.1.1 Visual Impairment (CZ: Zrakové Postižení) 5

1.1.2 Terminological Defi nition of the Target Group for Vision Rehabilitation 7

1.2 Classifi cation of Visual Impairment 7

1.3 Frequent Reasons of Reduction or Loss in the Czech Republic 9

1.4 Anatomical and Physiological Aspects of Vision 10

1.4.1 Basic Visual Functions and Disorders 11

1.4.2 Visual Cognition and Its Disorders 14

1.4.3 Visual Attention 16

1.5 Psychosocial Aspects of Visual Impairment 17

1.5.1 Specifi cs of Cognitive Processes 17

1.5.2 Specifi cs of Adaptation and Coping 22

1.5.3 Social Context of Visual Impairment 25

1.5.4 Impact of Visual Impairment on Quality of Life 28

References 34

2 Rehabilitation of Individuals with Visual Impairment in the Czech Republic 37

2.1 Development of Czech Rehabilitation Interventions in Brief 39

2.2 Theoretical Models of Rehabilitation 41

2.3 Rehabilitation Paradigm 42

2.4 Conditions and Principles of Rehabilitation Process 44

2.5 The Role of Special Education Approaches 46

2.5.1 Model of Educational Approach 48

2.5.2 Principles of Special Education of Individuals with Visual Impairment 50

2.5.3 Educational Methods and Techniques 50

2.5.4 Process and Forms of Education 51

2.6 The Role of Age Factor in Education 52

2.6.1 Specifi c Educational Approaches to Older Adults 53

2.7 Rehabilitation Programmes 55

2.8 The Role of Assistive Devices and Technology 57

References 58

3 Concept of Vision Rehabilitation in the Czech Republic 61

3.1 Development of Visual Rehabilitation and Training in Brief 63

3.2 Existing Approaches to Visual Training 64

3.3 Terminological Problems 65

3.4 Current Structure and Perspective of Vision Rehabilitation 67

3.4.1 Current Situation and Its Problems 67

3.5 Innovative Vision Rehabilitation Concept: Theoretical Postulates, Meanings and Objectives 72

3.5.1 Target Groups 74

3.5.2 Comprehensive Concept 75

3.5.3 Basic Factors 77

3.5.4 Visual Information Modifi cation 87

3.5.5 Assistive Devices and Technology 89

3.6 Vision Rehabilitation Process 98

3.6.1 Assessment and Individual Rehabilitation Plan 99

3.6.2 Visual Training Techniques 107

3.6.3 Visual Training Techniques 109

3.6.4 Supportive Techniques 122

3.7 Brief Notes on the Implementation of Visual Training 127

References 129

4 Reading as One of the Objectives of Vision Rehabilitation 135

4.1 Theory of Reading Performance 136

4.1.1 Assessment of Reading Performance in the Czech Republic 137

4.1.2 Reading Skills Development Strategies 144

4.2 Teaching Recommendations for Reading Skill Training 147

References 151

5 Objectives, Questions and Characteristics of the Research Group Involved in the Study 153

5.1 Objectives, Questions and Tasks of the Research 153

5.1.1 Research Objectives 154

5.1.2 Research Questions and Tasks 154

5.1.3 The Basic Research Question 154

5.1.4 Operationalization of the Basic Question into Partial Research Tasks 155

5.1.5 Additional Questions 155

5.1.6 Research Tasks 156

Contents

5.2 Characteristics of Research Groups 156

5.2.1 Frequency of Observed Group 159

References 159

6 Research Methodology 161

6.1 Research Planning 161

6.1.1 Research Situation 163

6.1.2 Structure of the Course of Rehabilitation Programme 165

6.1.3 Operationalization of the Programme 166

6.2 Methods of Obtaining and Recording Data 170

6.2.1 Method of Data Comparison 170

6.2.2 Method of Processing Anamnestic and Diagnostic Data 170

6.2.3 Method of Interview 171

6.2.4 Method of Qualitative Observation 171

6.2.5 Method of Dialectical Experiment 172

6.2.6 Experimental Factors 173

6.2.7 Method of Experimental Testing 173

6.2.8 Method of Experimental Measurements 174

6.3 Methods of Processing and Displaying Data 177

6.3.1 Coding Method 178

6.3.2 Displaying Data 179

6.3.3 Data Analysis of Case Study 179

6.4 Methods of Data Analysis 184

6.4.1 Mathematical and Statistical Methods 184

6.4.2 Qualitative Methods of Data Analysis 185

6.4.3 Structure of the Analysis of Qualitatively Verifi ed Relationships and Intervening Variables 185

References 187

7 Results of the Research 189

7.1 Results of Measurement: Individual Cases 190

7.1.1 Interpretation of Measurement Results: Proband A 191

7.1.2 Interpretation of Measurement Results: Proband B 192

7.1.3 Interpretation of Measurement Results: Proband C 194

7.1.4 Interpretation of Measurement Results: Proband D 196

7.1.5 Interpretation of Measurement Results: Proband E 198

7.1.6 Interpretation of Measurement Results: Proband F 200

7.1.7 Interpretation of Measurement Results: Proband G 202

7.1.8 Interpretation of Measurement Results: Proband H 203

7.1.9 Interpretation of Measurement Results: Proband I 206

7.1.10 Interpretation of Measurement Results: Proband J 208

7.1.11 Discussion to Individual Cases 209

Contents

7.2 Summary Results of the Measurements

of Reading Performance 210

7.2.1 Results in the Category of Reading Rate 210

7.2.2 Results in the Category of Reading Accuracy (Number of Errors) 226

7.2.3 Results in the Category of Reading Comprehension 243

7.3 Summary Results Achieved During the Experimental Programme 260

7.3.1 Summary Results and Discussion on Visual Acuity 261

7.3.2 Summary Results and Discussion on Age 262

7.3.3 Summary Results and Discussion on Reading Experience 262

7.3.4 Summary Results and Discussion on Activity 263

References 264

8 Conclusions 267

8.1 Conclusions of Empirical Research 267

8.2 Recommendations for Rehabilitation Theory 271

8.3 Recommendations for Rehabilitation Practice 273

8.4 Summary 276

References 277

Appendix A: Recommendation of implementation of the interdisciplinary research by the Ethics Committee of the University Hospital in Hradec Králové—English translation 279

Appendix B: Czech original 281

Appendix C: Members of the Ethics Committee 283

Index 285

Contents

List of Abbreviations

ADL Activities of daily living

ACVERP Academy for Certifi cation of Vision Rehabilitation and Education

ČUNS Česká unie nevidomých a slbozrakých (Czech Union of Low

Vision and Blind)

CVI Cortical visual impairment

CVR Comprehensive concept of vision rehabilitation

CZV Centrum zrakových vad v Praze (Centre of Visual Impairment

in Prague)

EBU European Blind Union

ERL Experimental rehabilitation lesson

ERP Experimental rehabilitation programme

FN HK Fakultní nemocnice Hradec Králové (University Hospital in Hradec

Králové, CR)

ICF International Classifi cation of Functioning, Disability

and Health ( WHO , 2001)

IRP Individual rehabilitation plan

OD Optical device

QOL Quality of life

ROP Retinopathy of prematurity

RP Reading performance

RQ Reading quotient

RRS Dědina Pobytové rehabilitační a rekvalifi kační středisko Dědina

(Dědina Residential Rehabilitation and Requalifi cation Centre)

RS Recording sheet

SONS Sjednocená organizace nevidomých a slabozrakých

(Unifi ed Union of Low Vision and Blind)

VA Visual acuity

VF Visual fi eld

VI Visual impairment

List of Abbreviations

About the Author

Kamila Růžičková , Ph.D is Assistant Professor in the Faculty of Education at the

University of Hradec Králové She has more than 22 years of experience with cation, rehabilitation and counselling for people with visual impairment She is an expert teacher and lecturer at the Education Centre for Children with Visual Impairment in Hradec Králové, an instructor of Orientation and Mobility skills and

edu-a teedu-acher of Bredu-aille code Previously, she worked edu-as edu-a professionedu-al edu-at the Rehedu-abilitedu-ation Center for Adults with Visual Impairment for 8 years She is the author of the edu-cational programme ‘Increasing visual performance in reading’ and a monograph,

Visual Rehabilitation for Persons with Low Vision Dr Růžičková works as a

mem-ber of the Czech Republic Governmental Committee for the special needs of people with disabilities and the Association of Professional Counsellors for children with special education needs and their families and teachers of the Czech Republic

© Springer International Publishing Switzerland 2016

K Růžičková, Reading Rehabilitation for Individuals with Low Vision,

Contemporary society has been further increasing the dominance of the munication of information through visual perception The reason is the advantage of visual form in terms of a high density of provided information and high level of graphic information through images (thanks to the use of advanced video technolo-gies) The society often defi ned as visuocentric has been building increasingly more barriers for persons with severe visual impairment

Severe visual impairment affects all social relations, performance, professional career and lifestyle, but it can also intervene with understanding their existence All

of these attributes mirror also in the creation of value orientation, which is closely related to the quality of life

According to WHO statistics, 285 million people are estimated to be visually impaired worldwide: 39 million are blind and 246 have low vision In the context of the ageing of population, also other facts must be taken into account: Almost 82 %

of persons living with blindness are aged 50 and above Uncorrected refractive errors are the cause of moderate and serve visual impairment Sight loss is closely related to old age—in the next 20 years, the number of persons aged over 85 years will approximately double, which suggests that also the number of the elderly with

visual impairment will increase 1 According to European Blind Union, an average

of 1 in 30 Europeans experience sight loss There are four times as many partially sighted persons as blind persons The average unemployment rate of blind and par-tially sighted persons of working age is over 75 % More women are unemployed than men Women are more at risk of becoming blind or partially sighted than men One in three senior citizens over 65 faces sight loss 90 % of visually impaired per-sons is over the age of 65

These data indicate, among other, the need for the development of social and rehabilitation arrangements (Krahulcová, 2002) ‘The last research of the Department of Assessment Medicine of the Institute for Postgraduate Medical Education in Prague (Katedra posudkového lékařství Institutu pro další vzdělávání

v Praze), based on the data of offi cial statistics, estimated the approximate ratio of population with low vision in the Czech Republic : approximately 20,000 persons who are blind and 161,900 persons with low vision’ (Jesenský, 2002 , 36)

Care, education and rehabilitation have a long tradition on the lands of Bohemia and Moravia, parts of the present Czech Republic Current development has been substantially infl uenced by it Signifi cant changes in the Czech special education were made possible by the change of political system in 1989 This date initiated a new period of development Twenty-fi ve years of it have shown that the level of the Czech system of social and rehabilitation services for adults with visual impairment

is in many areas comparable with other developed countries In a few selected areas, however, it is necessary to point out falling behind global standards

Severe impairment or loss of vision is a serious interference in the lives of als and their existence in community The starting point for any professional work in the area of education and rehabilitation is the understanding of the specifi c dimensions

individu-of quality individu-of life in the target group (Bendová, 2013 ) Jesenský ( 2002 ) marks the lowing dimensions: effective use of visual skills; overall physical condition; quality of health care; specifi c values and social status ; inclusion in a specifi c culture; voca-tional, fi nancial and social security and conditions of employment ; conditions for personal development and mental capacity; possibilities and conditions of socializa-tion and social inclusion ; other individual variables

Rehabilitation

When new systems, strategies and concepts of special education and rehabilitation are being developed, it is necessary to deal with a number of terminological prob-lems which special education has been facing up to now At this particular moment

1 Further statistical data on situation in the world are available in WHO reports; information on current situation in the Czech Republic is analysed by the study focusing on the issues of the qual- ity of life of persons with visual impairment (available from: http://www.sons.braillnet.cz ; down- loaded 2004-03-20) Cerha ( 2002 ) reports that 65 % of the clients of Tyfl oservis belong to the age group over 65 years

1 Visual Impairment and Its Impact on Development

of the development of the discipline, we feel the necessity of an interdisciplinary cooperation and intertwining the knowledge of very different fi elds of the science With the enormous growth of the level of interdisciplinary cooperation, the need of new terminological defi nitions has arisen which should refl ect the terminology of all the participating fi elds of the science There are many terminological discrepan-cies especially in this area, i.e the area of ‘helping professions’, which also includes comprehensive rehabilitation This conceptual inconsistency has been caused by a speedy and much uncoordinated development of complementary fi elds as much as

by the use of different paradigmatic models 2 The most likely source of confusion has been the infl uence of written papers coming from various countries, using different sets of terms (Růžičková & Balcarová 2006 ) Based on this, we would like to clarify the basic terminology used in this work

Health is, following the WHO defi nition, a state of complete physical, mental

and social well-being (WHO, 2001 )

Permanent health impairment disturbs the well-being of a person in all the three

dimensions mentioned above (Šťastný 2006 ) The primary cause of health

impair-ment is a disorder According to WHO ( 2001 ), it is a loss or an abnormality of the anatomical, mental or physiological structures of function of the organism A pri-mary disease (i.e internal situation) and its outer functional manifestation create a risk of the emergence of secondary changes at physical, mental, eventually social

levels, thus causing a drop in the abilities of the person which can result in decreased ability (impairment) and limited possibility to share in community life (i.e social

consequences) The term of impairment (or disability) is understood as the opposite word to the word ability (CZ—schopnost), which, in the above defi ned meaning, denotes an ability to exercise any activity in the way and extent corresponding with

norms Impairment ( CZ—postižení, znevýhodnění ) can be understood as a limited

ability or a disability of the person to exercise some activities in a similar way or as effectively as persons in the majority society

The degree of disability has been described in professional resources as a level of functional potential or development of the person, proportional to his/her age

Functional ability should be diagnosed on the basis of defi nition which assesses the

specifi c symptoms of individual target group by taking into account the threshold of decreased abilities (Fig 1.1 ) 3 In case of an adult, the result of complex functional evaluation is compared with the abilities of the adult without impairment with average abilities See ‘International Classifi cation of Functioning, Disability and Health’— ICF (Fig 1.2 ) 4

2 Types of models: medical, educational, sociological, anthropological, charity model, etc In any theoretical discipline, there may exist different general terms narrowly applied by the authors to various areas of problems or target groups

3 This model cannot be used as the only/primary testing method The problem consists in the

dif-fi culty to determine the threshold of ability in relation to the dynamics of personal development , conditions, successful rehabilitation and other specifi c variables

4 International Classifi cation of Functioning, Disability and Health ( ICF ) was agreed by the World Health Organisation in 2001 ( WHO , 2001 ) Except for medical diagnosis, it also takes into account the limited activity concerning participation in social life, real social and material conditions, etc (Švestková, 2005 )

1.1 Basic Terminology and Defi nitions in Vision Rehabilitation

In case that the real consequences of disorder have an impact on the process of social interaction, education, employment , social and cultural life (and consequently also on the very area of meaning of existence and life), we can talk about disability (CZ—postižení)

The emergence of disability is defi ned in professional resources from various perspectives Jesenský ( 2000 ) classifi es it, on the basis of anthropological paradigm, through the assessment of quality of life On the other hand, Schuntermann ( 1996 ) defi nes handicap on the basis of the level of inclusion into majority society in all the key areas of life in which the individual is willing to participate

The term at risk (CZ—ohrožení) also emerges in professional literature It is mainly used in the context of the target group of children at risk of developing a disability

The International Classifi cation of Functioning, Disability and Health ( ICF ) helps to disclose the reasons and relationships of reduced ability, impairment and

ICF Biopsychosocial Model

(Mutual relationships of components)

Health problems

and structures

Fig 1.2 The biopsychosocial model of aspects of health and their relationships (ICF, 2001 )

_ _ _ _ _ _ _ _ _ _ _ _ _ Reduced abilities

Fig 1.1 Model of the continuum of seriousness of disability shows the border separating the abilities

comparable to population without disabilities and the limited abilities (Douglas et al., 2012 )

1 Visual Impairment and Its Impact on Development

1.1.1 Visual Impairment (CZ: Zrakové Postižení)

We can also fi nd in professional texts the following terms describing visual abilities : visual impairment (CZ—zrakové postižení), visual disorder (CZ—porucha), disabil-ity (CZ—znevýhodnění) Persons are called: person with low vision (CZ—osoba slabozraká), with total visual impairment (or with blindness = nevidomá) or near-total visual impairment (with legal blindness = prakticky nevidomá) Relationship between disease/disorder, reduced ability, impairment and disability shows the terminology of ICF classifi cation also in offi cial translations to respective languages The table (Fig 1.3) provides the classifi cation including the examples of application Consistently with the up-to-date anthropological approach, the term ‘individuals with

handicap’ is being replaced by the term ‘ individuals with special needs ’ (CZ—‘osoby

se speciálními potřebami’) (Květoňová-Švecová, 2004 )

The classifi cation of various types of visual impairment following WHO ( 2001 ) creates categories on the basis of the quality of visual functions which, after the medical therapy and correction of refractive defect, show values: visual acuity less than 0.3 (6/18) and/or fi eld of vision around central fi xation limited to less than 10°

Functional visual performance is a term well suited to the needs of rehabilitation

practice It is defi ned as the level of functional use of visual potential in cooperation

of life of the patient

Social consequences

Difficulties in performing activities of daily living

Reduced social ability or ability to play certain roles in society Anatomical

structures

Physiological functions

Degeneration

of photorecep- tors

Central scotoma, distorted vision

Impairing the ability of face recognition, etc.

Fear of rejection by friends, reduced independence

Fig 1.3 Relationship between disease/disorder, reduced ability, impairment and disability (Dickinson, 2002 , 4)

1.1 Basic Terminology and Defi nitions in Vision Rehabilitation

with visual ability, taking into account also cognitive, conative and environmental elements 5 (Lueck, 2004 )

The term rehabilitation , introduced during nineteenth century, was understood as

restoring someone’s abilities again (LAT—re = again, habilis = able) with the aim of repairing the damaged function of the organism However, the meaning of the term has been stretched in current understanding According to the WHO , rehabilitation

is ‘a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels’ Nowadays, the term ‘rehabilitation’ works with a spectrum of objectives, from minimum to maxi-mum The optimal objective aims for a return to full physical, mental and social condition If not possible, alternative objectives are specifi ed Its objectives are specifi ed as the effort to minimize the defect, disability or impairment and to pre-vent the emergence of secondary negative phenomena and processes ‘The target group of rehabilitation are persons with motor, sensual, mental, speech, psychologi-cal impairments, persons with impairments based on oncological, metabolic, aller-gic and other problems and their combinations In terms of age, it concerns all age categories’ (Švestková in Votava & Buchberger, 2005 , 12)

Rehabilitation of individuals with visual impairment (CZ—rehabilitace osob se

zrakovým postižením) according to European Blindness Union is ‘a modern defi tion (re)habilitation has a holistic approach far beyond the health sector and embraces a wide range of issues including education, social counselling vocational training, transport, accessibility and assistive technology’ Jesenský ( 2003 ) defi ned rehabilitation as the process of capacitating those with undeveloped, lost visual functions

Special education of individuals with visual impairment (CZ—tyfl opedie) is

most frequently defi ned as the area of special education and learning of persons with low vision (Edelsberger & Kábele, 1984 ) In Czech practical training, it has mostly been a part of pre-graduation studies However, in accordance with the development of understanding of education as a process of lifelong learning, it is necessary to perceive this particular area of special education in the wider sense Its inherent part is special education consultancy and rehabilitation (Květoňová- Švecová, 2000 ) In Czech theory, general adult education (CZ—obecná andra-

gogika) has been rather aimed at the processes of shaping the personality in the areas of self-education and self-realization , which has led to a tendency to under-

stand education as organized intentional activity However, this understanding does not fully respond to the needs of special adult education and the necessity to under-stand education in its widest meaning and to respect the philosophical, anthropo-logical and learning paradigm of education in relation to all stages of life (Mühlpachr, 2004 )

Vision rehabilitation (CZ—rehabilitace zraku) according to American Foundation

for the Blind includes ‘a wide range of professional services that can restore

5 Visual performance has been more frequently related to being diagnosed during basic activities and conditions—it is interested in the ability of a specifi c person in critical situations (Lueck,

2004 )

1 Visual Impairment and Its Impact on Development

functioning after vision loss’ Jesenský ( 2007 ) defi ned vision rehabilitation as ‘a system of rehabilitation procedures for persons with low vision’ According to the modern concept, emphasis is placed on the involvement of the potential of whole personality as well as social and object environment Thus, vision rehabilitation can

be defi ned as education towards the use of a set of knowledge, skills and habits contributing to the optimal use of visual capacity (Růžičková, 2015 )

1.1.2 Terminological Defi nition of the Target Group for Vision

Rehabilitation

Selection of an exact chain of terms to defi ne the target group of potential vision rehabilitation users required the solution of a terminological problem as the termi-nological defi nition of target group does not exactly match the defi ned categories of visual impairment classifi cation according to the WHO It is not only persons whose visual ability corresponds with the category ‘low vision’ but also a part of the cate-gory ‘near-total visual impairment’ However, regardless of such terminological discrepancies, the general term ‘low vision’ or ‘persons with low vision’ has been used throughout this study

Visual disorder can be classifi ed from many perspectives The basic criteria are: time and reason of emergence; type and degree of partial visual ability; etc The assessment and evaluation of the level of visual abilities in special education as well

as vision rehabilitation is based on the ophthalmological classifi cation of WHO

2001 (Fig 1.4 ) However, the ophthalmological classifi cation based mainly on the ability of central visual acuity cannot be suffi cient diagnostic material for special education or rehabilitation practice 6 For these purposes, other classifi cation criteria are also used, on the basis of which other factors substantial for development , edu-cation and rehabilitation are assessed The aim of these criteria, besides the evalua-tion of functional visual abilities, skills and experience, is also the assessment of external conditions and personal competences of the individual In this context, we can talk also about the detection of biological, psychological and social infl uences (Vágnerová, 1999 )

6 The traditional medical model of assessment still prevails in the Czech Republic However, it cannot suffi ce due to the lack of information on the patient Special education diagnostics or ergo- diagnostics is used in Czech situation for instance for the creation of individual rehabilitation plans In most cases, however, it is not based on exact methods or test batteries and an interdisci- plinary team of experts does not participate in it; thus, the evaluation cannot be considered comprehensive

1.2 Classifi cation of Visual Impairment

Information about the person collected through medical, psychological, special educational and rehabilitative diagnosis brings together a comprehensive basis for the most accurate specifi cation of the needs of the person to design an individual educational or rehabilitation plan and a prognosis of further development Based on the analysis of several professional sources (Jesenský, 2000 ; Květoňová-Švecová,

2000 ; Ludíková, 2003 ; Požár, 2000 ), a summary of classifi cation defi nitions is given below which brings together the criteria infl uencing educational and rehabilitation process These are the criteria which should be assessed within a comprehensive diagnosis:

1 Classifi cation by aetiology : organic or functional

2 Classifi cation by the period of the occurrence of disorder: congenital, acquired (juvenile, senile)

3 Classifi cation by the progression/prognosis of disorder: regressing, stable, progressive

4 Classifi cation by the type of visual disorders: loss of visual acuity , changes in the width of visual fi eld, oculomotor disorders and binocular vision disorders, impaired colour discrimination , reduced contrast sensitivity, diffi culties in processing visual information

5 Classifi cation by characteristic symptoms: acute, chronic or recurrent

6 Classifi cation by age: infants and preschool age , school age , adults and elderly adults

7 Classifi cation by social background: functional, dysfunctional, absent

Levels of visual impairment

1. Moderate visual impairment

Visual acuity with best possible correction: maximum less than 6/18 (0.30) –

minimum equal to or better than 6/60 (0.10); 3/10 - 1/10, Category 1

2. Severe visual impairment

Visual acuity with best possible correction: maximum less than 6/60 (0.10) –

minimum equal to or better than 3/60 (0.05); 1/10 - 10/20, Category 2

3.

Profound visual impairment

a) Visual acuity with best possible correction: maximum less than 3/60 (0.05) – minimum equal to or better than 1/60 (0.02); 1/20 - 1/50

b) Concentric constriction of the visual field of both eyes less than 20° or the better eye less than 45°, Category 3

4.

Near-total visual impairment

Visual acuity with best possible correction 1/60 (0.02), 1/50 up to light perception or the constriction of visual field up to 5° around central fixation, even if central visual acuity is not affected, Category 4

5. Total visual impairment

Loss of vision including conditions from no light perception to the preservation of light perception with incorrect light projection, Category 5

Fig 1.4 The International Classifi cation of Diseases and Related Health Problems (ICD-10)

1 Visual Impairment and Its Impact on Development

8 Classifi cation by the presence of additional disadvantage: changes in appearance, combination with another or several specifi c impairments 7 and another discrimi-natory or incapacitating situation of permanent nature which complicates learning, education, rehabilitation and social inclusion

In terms of further development of the fi eld of comprehensive special education

of persons with visual impairment, it is appropriate to introduce the ICF diagnostic system which is based on the functional assessment of the impact of disability on quality of life from organic, functional, social and environmental points of view This particular type of classifi cation makes it easier to understand the complicated issue of causes and relationships between reduced abilities and the impairment

1.3 Frequent Reasons of Reduction or Loss in the Czech

Republic

Even though this work concentrates on the visual problems of adults, it is suitable

to include also the aetiology of congenital eye disorders From the point of view of special education, such persons become a specifi c target group of vision rehabilita-tion In case of the aetiology of childhood total visual impairment (up to the age of 5), Květoňová-Švecová ( 2000 ) provides following data: 55 % prenatal infl uences;

14 % infectious diseases (rubella, toxoplasmosis, etc.); 9.3 % retinopathy of mature infants ; 5.4 % neoplasms (retinoblastoma, etc.); 3.1 % general diseases (rheumatisms, etc.) One of the most frequent reasons of congenital disorders of vision is retinopathy of prematurity (ROP) 8 The most common diagnoses of pre- school age are disorders of binocular vision, juvenile macular degeneration, con-genital cataract , optic nerve atrophy, congenital glaucoma, achromatopsia and more serious forms of refractive defects All the above-mentioned disorders, how-ever, can be progressive or can be complicated by other eye diseases 9 One of the functional visual disorders which can also develop because of various aetiologies and at various ages is cortical visual impairment ( CVI ), which is a central nervous system disorder

For adult population, diabetic retinopathy is considered the most frequent reason

of total visual impairment (blindness) 10 Further reasons for visual impairment of persons older than 40 years are glaucoma and age-related macular degeneration of

7 ‘In adulthood and old age, the most frequent combinations are those with physical and ing impairments, internal diseases (diabetes mellitus, etc.) and senile dementia’ (Moravcová,

retina ( ARMD ) 11 (Gubková, 2002 ) It is necessary to mention also eye injuries The injuries of one eye of various levels of seriousness prevail in clinical practice These are usually traumatic injuries caused by chemicals or perforation Damage may cause a reduction of visual acuity , amblyopia ; in some cases, other complica-tions can occur resulting in the development of other eye diseases (Řehůřek, 1997 ) Moravcová ( 2004 , 37) states that ‘it is possible to diagnose a signifi cant deteriora-tion of visual ability in 90 % of persons over 60 years as well as hearing ability in

30 % of persons over 60 years’ 12 SONS research (In Jesenský, 2002 , 15) published the following data about the relative distribution of causes of visual impairments:

‘31 % congenital or hereditary visual disorder, 27 % eye disease, 11 % injury and 7 % diabetes mellitus In terms of time of origin, 17 % of persons reported a defect from birth, the rest of the group developed visual disorders during the course of life’ The data clearly show the signifi cant superiority in numbers of persons over 60 years as compared to other groups as well as the prevalent occurrence of persons with low vision in comparison with the number of persons with complete loss of vision Vision is a very complicated and complex process based on learning It must be seen in three basic dimensions— visual perception , visual cognition and visual per-

formance Visual perception is the process of obtaining input information to the brain Visual cognition provides the processing of obtained data through the CNS and visual performance is the level of skill to use visual abilities functionally in specifi c activi-

ties, especially in critical situations 13 (Dickinson, 2002 ) A suffi cient level of standing anatomy, physiology, neuropsychology and their pathology is necessary for professionals to increase performance through education and rehabilitation

The knowledge of the rules of anatomy and physiology of vision and their pathology applied to the specifi c eye disease diagnosis is very important starting information for the professional worker in the area of special education and rehabilitation Such infor-mation makes it easier to communicate with the ophthalmologist, to understand the nature of limitation of visual ability in every specifi c case, and, last but not least, also

to choose optimal educational, training and supportive strategies and techniques

11 WHO statistical data ( 2001 ) show that ARMD is the most frequent cause of visual acuity loss in persons older than 60 It is estimated that in the developed countries more than 2.5 million persons suffer from it, with the annual increase of approximately 200,000 persons However, the ARMD generally does not result in total visual impairment, more often it results in moderate to profound reduction in vision, i.e loss of central vision and visual acuity (Sosna, 2002 )

12 Similar data about the structure of patients with visual disorders are given in the analysis of patients by the Centre of Visual Impairment in Prague (Centrum zrakových vad v Praze, CZV) conducted on the sample of 622 patients (Moravcová, 2004 )

13 The term ‘critical situation’ must be understood as a situation which is for the person visually demanding or diffi cult to manage

1 Visual Impairment and Its Impact on Development

This chapter summarizes the importance of vision rehabilitation of persons with low vision with reference to existing professional information resources Because of the wide reference fi eld of this presented work, we do not include the issue of anat-omy and physiology of vision, characteristics of eye diagnosis or the ways of clini-cal examinations which have been well described by a number of other authors 14

1.4.1 Basic Visual Functions and Disorders

Vision is a very complicated and complex process based on the synthesis of the abilities of visual analyser From the ophthalmologic point of view, the basic func-tions of vision are acuity, width of visual fi eld, colour discrimination , contrast sensitivity, spatial vision, resolution and adaptation to light and darkness In terms

of rehabilitation, the basic precondition for every educational and rehabilitation intervention is complex diagnosis of visual ability

Central visual acuity is defi ned as the ability of the eye to perceive clearly and

sharply objects and their details The key component is the ability to distinguish two points An important role is played by the correct ratio of refraction of optical environ-ments and sagittal length of the eyeball Deviations from the norm are called refractive disorders (myopia, hypermetropia, astigmatism , etc.) The ability to have sharp vision

at various distances is ensured by the accommodation of the eye Its basic function is mainly the accommodation of near vision The diagnosis of central visual acuity is measured with acuity tests In problematic cases, it is suitable to examine near vision acuity with the help of special acuity tests (for instance, texts of graduated scale of sizes

or other non-alphabetic characters) 15 Visual acuity also depends on other variables such as intensity of illumination With increasing intensity, acuity increases up to the limit of glare, after it acuity decreases again (Pokorná, 2000 )

Visual fi eld (VF) represents the sum of all points displayed on retina when the

eye does not move Boundary is defi ned by the rim of the orbit including the brows, nose, cheeks and eyelids Visual fi elds of both eyes overlap about 60° around the fi xation point, thereby enabling stereoscopic vision (Kolín et al., 1994 ) Visual

eye-fi eld can be classieye-fi ed into central (up to 30° from the fovea) and peripheral The function of peripheral vision consists mainly in spatial orientation and vision in low light conditions (scotopic vision) Transition from photopic vision (retinal cones) in the centre to scotopic vision (retinal rods) at the periphery is gradual With closer distance to the periphery, the ability to distinguish colours decreases (fi rst the ability disappears to perceive green, then red; blue and yellow are perceived for the longest time); visual acuity is also gradually decreasing (Kvapilíková, 1999 )

14 Kraus et al (1997) , Kolín et al (1994) , Řehůřek ( 1997 ), Divišová et al (1990) , Řehůřek, 1997 ; Koukolík ( 2002 ), Kulišťák ( 2011 ), etc

15 The most frequently used tests of visual acuity are: Snellen charts, LogMAR charts, Pfl uger hooks; for near acuity: Jaeger charts, LogMAR charts, Lea Hyvärinen test batteries ( Kraus et al.,

1997 ; Moravcová, 2004 )

1.4 Anatomical and Physiological Aspects of Vision

Visual fi eld disorders occur as the result of damage to retina, visual pathways or brain centre, paralysis of upper eyelids or in connection with severe limitation or exclusion of the function of one eye Another reason of visual fi eld limitation can be the use of spectacle correction and special optical devices Deviations in visual fi eld can have the following character: concentric narrowing (the number of degrees decreases from the periphery to the point of fi xation), central fi eld loss (scotoma), hemianopia (loss of one half of the VF), quadrantanopia (the loss of vision is located

in the area of brain damage) In other cases, it is possible to observe a variety of shapes and locations of vision loss throughout the entire visual fi eld (Kolín et al.,

1994 ) Central scotoma causes complications especially in near-distance activity; concentric narrowing, on the other hand, causes diffi culties especially in spatial orientation and mobility Scotoma can be relative (reduced quality of images) or total (vision is excluded in the place of scotoma) For the examination of vision fi eld, kinetic and static perimetry is used 16 Some visual disorders can affect the reality

of image In such case, image distortion (metamorphopsia) has to be examined 17 (Kraus et al., 1997 )

Eye movements are performed by six extraocular muscles, which control the movements in nine visual directions Binocular vision is defi ned by Květoňová-

Švecová ( 1999 ) as the coordinated sensorimotor activity of both eyes enabling to create a simple spatial image (stereopsis) Such a connection is the prerequisite of depth (spacial, three-dimensional) perception Different visual acuity in the two eyes (or other obstacles) causes the inability to link the images of both eyes into a single binocular image (fusion) (Kraus et al., 1997 ) As a result of the perception of image without stereopsis, the perception of objects becomes the most affected area (secondarily also the formation of concepts is affected—especially perception

of space, sensorimotor coordination and fi ne motor skills of the hand) (Vítková,

2004 ) New researches into the functions of human brain show that the dimensional perception of objects largely depends on visual learning from a very early age (Koukolík, 2002 )

The most common eye movement disorders are strabismus in childhood and gaze palsies in adulthood In case of strabismus, only one eye may be affected, or both eyes alternate in fi xation and deviation ‘Eye movement disorders lead to the reduction of sensation in one eye which is subsequently fi xed as amblyopia or dip-lopia in adulthood’ (Kraus et al., 1997 ) If a visual disorder develops in the dominant eye, spatial vision gets disrupted; often the problem is also the diffi culty of the patient to refocus on the use of non-dominant eye In such case, it is necessary to indicate the occlusion of the dominant eye for near-distance visual tasks (Moravcová,

2004 ) Binocular vision examination is performed by examining ocular fundus and

16 Modern kinetic perimeters include for instance Goldman chart and Hart chart Both types allow the adjustment of light intensity and colour of fi xation point They also allow the examiner to observe the sequence of patient’s fi xations ( Kraus et al., 1997 )

17 For a preliminary examination of deviations, Amsler Grid can be used

1 Visual Impairment and Its Impact on Development

detecting deviations Both diagnosis and actual training of simple binocular vision are carried out on special devices by orthoptists (Květoňová-Švecová, 1999 ; Divišová et al., 1990 , etc.)

Colour perception is a process based on the activity of photosensitive cells in the

retina The irritation of retina by the light signals of different wavelengths of visible light stimulates cone cells This means that colour perception is affected by the impact of the distance of an image from the macula The central part of retina allows for a more accurate colour perception, towards the periphery the ability gradually declines (Hofmannová, 1993 ) In terms of biochemistry, the pigment rhodopsin is responsible for colour vision It is found in cone cells and contains three compo-nents capable of reacting to various electromagnetic waves in the range of visible spectrum Researches have shown that humans are able to recognize more than 150 colours and altogether about 2000 shades 18 The diagnosis of colour perception can

be performed through various methods The most frequently used include matic and numerical methods, letter charts and test batteries of shades of colour spectrum 19 (Kraus et al., 1997 )

The quality of colour discrimination is also infl uenced by external factors (light intensity, hue, colour saturation, brightness and contrast ) and related adaptation In this context, many persons with low vision lose the ability to accurately recognize the subtle shades of colours At very low levels of light, the eye cannot distinguish colours at all (Macháček, 2002 )

Adaptation of the eye is the ability to adjust to different light intensity, i.e the

abil-ity of the eye to change the threshold of sensitivabil-ity to light Adaptive capacabil-ity is determined by the regeneration and synthesis of visual pigments in the retina At a higher light intensity, dominant function is taken over by cones (photopic vision); during transitional period (in deteriorated lighting conditions), it is a synthesis of the function of cones and rods (mesopic vision); at low levels of light, the function of cones is being phased out and rods take over (scotopic vision) For the examination

of adaptation to darkness , adaptometers are used 20 The result of examination is adaptation curve During the examination of adaptation to glare, central acuity is being tested under standard lighting conditions It is followed by dazzling the eye with the ophthalmoscope, and time is measured how long it takes for the patient to read the same line of optotype (Kraus et al., 1997 )

Permanently increased or decreased sensitivity to light and contrast occurs in many persons with low vision There are two types of the most frequent adaptation problems: nyctalopia (night blindness) and photophobia Adaptation process can be disproportionally long or adaptation can take place only partially or not at all

18 Based on the research, two types of colour perception are further differentiated: dominator tated by the whole spectrum of wavelengths in visible spectrum) and modulator (responsive only

(irri-to a certain narrow range of wavelengths—blue: 450–470, green: 520–540, red-yellow: 580–

600 nm) ( Oláh et al., 1998 )

19 The Farnsworth Munsell 100 Hue Test, Lanthony 40 Hue Test, etc ( Kraus et al., 1997 )

20 For instance, Hartinger adaptometer ( Oláh et al., 1998 )

1.4 Anatomical and Physiological Aspects of Vision

(Jesenský, 1994 ) In such cases, it is necessary to use additional tests for diagnosis

to specify the quality of the recognition of faces, traffi c signs, etc in various lighting conditions (Kraus et al., 1997 )

1.4.2 Visual Cognition and Its Disorders

The process of vision, beginning on the retina of visual analyser, transforms the image into a neural image; its fi nal quality depends on the quality of information processed in brain centres An important role is played by learning, previous visual and other experiences, but also other factors (emotional state, will, etc.)

The ability of visual perception and cognition and its disorders caused by brain

damage is considered a very important part of the comprehensive approach to vision

rehabilitation The process of visual analysis proceeds in two stages The lower

stage—discrimination—ensures the resolution and recognition of objects based on their basic qualitative properties The higher stage—differentiation—evaluates also

other features, reactions, position and complex properties of the object Synthesis

concerns the developmentally higher process of generalization, which builds on the analysis (Jošt, 1998 ) Disorders of the cognition of persons, things and their impor-tance or spatial relations through an otherwise intact eye are clinically defi ned as

visual agnosia Object agnosia has, according to Lissauer (in Koukolík, 2002 ), two

basic forms Apperceptive agnosia : visual cortex distinguishes essential

compo-nents of the observed stimulus, but cannot integrate them into a meaningful whole The diffi culties are evident in distinguishing between simple and complex drawings

or fonts 21 (the person is unable to perform tasks in imagination based on spatial

rota-tion; however, he/she is able to distinguish the basic geometrical shapes) Associative agnosia : the obstacle consists in the impossibility to assign a correctly identifi ed

stimulus to the appropriate concept (the person can distinguish a stimulus and its individual features; however, he/she cannot name it)

Recognizing shapes (geometrical, numeral, alphabetic symbols) When

diagnos-ing such a disorder, it is necessary to eliminate the situation where the failure can be caused by a poor quality of visual material

Three-dimensional perception depends very much on visual learning in early

childhood, when visual system is still very pliable To recognize specifi c shapes of buildings, faces or letters, cortical areas were found at the border of occipital and temporal cortex on the inner surface of hemispheres Visual stimuli are processed in such a way by the brain so that certain types of neurons respond to individual features of the object (shapes, direction of movement, spatial depth, colours) There are visual areas at the rear part of temporal cortex which perform synthesis and compare it with the record in long-term memory

21 One form of it is ‘word blindness’ ( alexia ) Such a person can write but not read written text ( Otradovec, 2003 )

1 Visual Impairment and Its Impact on Development

Visual differentiation is a comparison of two or more two-dimensional or three-

dimensional shapes/patterns 22 The diagnosis of the ability of visual differentiation from the point of view of functional assessment is focused at the fi rst stage on the ability to distinguish differences At the second stage, it is performed under similar conditions as in the previous case and is aimed at the determination of boundaries

of the ability to distinguish detail with regard to environmental conditions

Recognizing colours An important quality of visual parts of the brain is the

abil-ity to attribute constant colour to the surface of various objects regardless of the type

of lighting The existing research has shown that the brain processes colour stimuli

in three stages: stage 1 is characterized by the activity of primary visual cortex, which registers the presence and intensity of the colour components of the stimulus and distinguishes different wave lengths of light from the retina; stage 2 takes place

in the remotest area of visual cortex and is dealing with the problem of colour stancy; stage 3 deals with the colours of objects and takes place in the lower parts of temporal cortex and frontal cortex 23 (Šikl, 2012 )

Recognizing movement When a movement is registered at the periphery of

visual fi eld, the saccadic transfer of attention to this particular object occurs This brings the object into the central visual fi eld where it is examined through slow tracking movements According to Atkinson et al ( 1995 , 181), ‘the human eye can much better perceive movement on a structured background (relative move-ment) than on a dark or neutral background (absolute movement)’ Motion per-ception disorder (akinetopsia) is a rare disorder associated with a limited ability

to determine the direction of movement 24 A specifi c form is the unilateral spatial agnosia in which everything is ignored which happens in one half of visual fi eld (Otradovec, 2003 )

Recognizing face raises complex brain activity, part of which is also assigning

the name to the person It has been proven that the ability to recognize faces has no

relationship to the ability to recognize other objects ‘ Prosopagnosia is the failure

to recognize human faces which is a consequence of brain damage’ 25 (Koukolík,

2002 , 55) The corrective educational techniques are, in case of all types of agnosia ,

22 The category of differentiation includes for instance the ability to recognize persons by appearance (Koukolík, 2002 )

23 Problems with colour recognition are described in professional resources as: cerebral

achroma-topsia (syndrome of partial or complete loss of the ability to see colours as a result of brain

damage); colour agnosia (the person sees colours but cannot distinguish them); colour anomia (the person sees colours but fails to name them) and dyschromatopsia (person confuses colours)

1.4.3 Visual Attention

Visual attention is a part of the complex system of attention defi ned by Šikl ( 2012 ) as

a dynamic regulatory, control and coordinating function characterized by selectivity, concentration and focus of mental activity of the person According to the theory of Treisman ( 1986 ), certain types of visual processing are carried out automatically; other arrangements of elements in the reference fi eld evoke the reaction of focused attention The fi rst type of analysis is called ‘search for an outstanding feature’; the second type ‘search for a combination of characteristics’ According to this theory, it

is possible to conclude that vision at early age saves some simple and useful ties of the observed scene into maps which can preserve the spatial relations of what was seen; however, the maps are not able to use the information in subsequent pro-cessing stages Instead, it is the focused attention which selects and combines the characteristics presented in various locations In later periods, integrated information serves to create sets of perceived objects; the contents of set are compared with the description stored in the cognitive network (Kulišťák, 2011 ) The assessment of extent and quality variations in abilities belongs to the domain of neuropsychology Apart from determining the actual ability as such, the diagnosis of the use of functional visual capacity is also important (it points to the level of effectiveness of the use of individual abilities in activities of daily living ) In rehabilitation of persons with cortical visual impairment ( CVI ) developed in adulthood, it is necessary to respect the recommen-dations of neurologist (Moravcová, 2004 )

proper-26 This is proven by cases when persons cannot recognize objects visually but they can imagine them visually, whilst others are not able to form the visual image of an object which they visually recognize

27 Bonnet syndrome develops after an eye disease It is associated with several types of visual lucinatory experiences: hallucinations of landscapes and persons wearing hats, hallucinations of grotesque or distorted faces, etc Visual hallucinations of Alice-in-Wonderland syndrome are char- acterized by a bizarre distortion of visual perception (Kulišťák 2003 )

hal-1 Visual Impairment and Its Impact on Development

Vision is an important source of stimuli necessary for the harmonious ment of human psyche Reduction or exclusion of visual control causes sensory deprivation with diffi culties at the level of activity, cognition, understanding and experience

Vágnerová (215) defi nes personality as ‘a relatively stable system of

intercon-nected somatic and mental functions which determines the experience, thinking and behaviour of the person’ This determines the relationship of the person to society and environment, both of which further affect person’s development and position in society

Psychology of persons with low vision (CZ— psychologie osob se zrakovým

postižením) deals with the specifi c infl uence of visual disorders on mental ment of the person The aim is to detect the patterns of optimal mental development and to maintain mental health under the infl uence of various types and forms of visual disorders or defects It is specifi cally important for persons with acquired disorders as it helps to overcome the negative consequences of the loss of perfect vision 28

The understanding of the specifi cs of development of the personality of als with visual impairment can be approached on the basis of a number of criteria which can facilitate an understanding of both internal and external determinants of development : level of person’s development , characteristics, current conditions and situational variables 29

Depending on the level of impairment, age at the time of its occurrence and other indicators, tendencies can be predicted as to the changes in development of cognitive processes as well as changes in lifespan emotional development Such changes can in turn infl uence self-esteem, performance, social relationships, career and other important areas (Vágnerová, 1995 )

1.5.1 Specifi cs of Cognitive Processes

Litvák ( 1979 ) states that the study of the psyche of persons with low vision can be successful only when supported by the results of general, developmental and educa-tional psychology A number of patterns discovered by general psychology fi nd its confi rmation in the development and manifestations of the psyche of persons with visual impairment

28 Souček ( 1992 , 23) states that ‘severe visual impairment in adulthood should not have a major impact on the change of personality ’

29 More specifi cally was the issue dealt with by Langrová ( 2005 )

1.5 Psychosocial Aspects of Visual Impairment

1.5.1.1 Perception

Visual perception provides most of the information on the basis of which the person creates a more complex picture of the world It is mainly the recognition of processes associated with one’s own organism, objects and properties of the environment, relation-ship between them, occurring changes, movement, etc The processing of sensory infor-mation is a prerequisite for purposeful activity enabling situational adaptation (Nakonečný, 1998 ) If we understand perception as a complex process of selection, clas-sifi cation, interpretation of certain stimuli and their integration into an existing informa-tion system, then reduction in the quality of visual perception presents a problem immediately in the initial stage of the described process

The quality of visual images is based on the degree of globality and accuracy of visual stimuli which a person can perceive and further specify on the basis of infor-mation obtained other than visual way Nakonečný states: ‘For the description and characterization of a perceived image, the term “phenomenal world” was coined to express its individually typical depiction The variable change of sensitivity may then be refl ected for instance in the group of persons with low vision, colour blind persons, etc’, The development of vision on the basis of visual learning occurs dif-ferently in children with congenital disorder and persons with later acquired visual disorder Children may, at the level of inadvertent use of visual potential, get only very little of suffi ciently specifi c and structured information, which is often quite insuffi cient for the development of visual imagination and memory They therefore have to learn how to build and use visual memory with the help of adaptive tech-niques 30 The level of imagination of an individual with congenital visual impair-ment depends not only on the degree of visual functions, but also on the level of built-up capacity for visual learning, imagination and memory (Růžičková & Hordějčuková, 2015 )

With regard to learning and use of visual memory , persons with acquired disorders, with their visual memory built on concrete and precise visual images, are in a dif-ferent situation They can use images perfectly well even in case of imperfect visual sensations It is therefore clear that an already existing visual memory has a distinc-tive potential which has to be supported by a purposeful, systematic training of visual stimuli decoding and assigning to existing visual images Persons with low

vision may have different threshold levels of sensations The thresholds were

clas-sifi ed by Nakonečný ( 1998 ) into four basic types: lower absolute threshold, upper absolute threshold, difference threshold and movement registration threshold Sensation thresholds change during development ; they correspond with the overall level of activation and are infl uenced by learning and training Extreme changes can

30 Barraga ( 1976 ) states that ‘the ability to create visual images and the development of visual memory in children with low vision is a developmental issue It is a complex pattern of learning within which the child learns to track objects especially “for near”, with the support of information modifi cation and thus also stimulation of visual pathways in the brain Accumulation of visual information and their later differentiation enables also development at the level of reverse recalling

of previously acquired images and memories.’

1 Visual Impairment and Its Impact on Development

on the stimuli which are accessible and understandable

Reaction time tends to be prolonged in the process of perception of persons with

low vision Nakonečný ( 1998 , 171) defi nes it as ‘the time that elapses from emergence

of the stimulus to response to it’ The reaction time depends on the condition and tion of the receptor, the current level of mental activation, the intensity of acting stimu-lus and other factors 31 The response must be preceded by orientation in the situation and the choice of the type of reaction (Langrová, 2005 ) Even in the case of ‘slow’ decision, the person is disadvantaged because of the limited possibilities of visual control and sensation During a swift decision (which in a number of situations may involve also security risk), persons with low vision are forced to respond on the basis

func-of an insuffi cient quantity and quality func-of both visual and compensation information; therefore, a mistaken or imprecise response is more probable

Objectivity of perception is defi ned as assigning perceptions to the already known

in the holistic context of the environment (Atkinson et al., 1995 ) If we relate this theory to the reduced visual perception of persons with low vision, two reactions may occur: If the person is able (using experience, cognition, etc.) to assign the stimulus to a particular object through visual perception, then he/she can further work with it in a more specifi c way (the information helps to analyse object’s char-acteristics); if the person is unable to assign the stimulus, he/she may attempt to gain information by purposeful behaviour (by reducing relative distance, by lighting, eventually by using other sensory analysers) If the stimulus remains in the area of unassigned sensation, it cannot become a sensation with its above listed information competences Beliveau and Smith ( 1980 ) published a similar theory of visual cognition

of persons with low vision 32

31 For example, fi gure-ground contrast , speed of induction and remission extent of changes in ulus (Nakonečný, 1998 )

stim-32 They rely on the research results which correspond to three conclusions concerning the tion of objects and images: creation of an internal image of the object or memory of it is a very slow process, proceeding in qualitative phases Specifi cally, it is collecting single pieces of knowl- edge about the properties of the object; the properties of the object are what provide most informa- tion; memory traces recording these properties together form the overall internal image

recogni-1.5 Psychosocial Aspects of Visual Impairment

The infl uence of expectation and context of perception were described by

Vágnerová The way how the object is perceived depends on the context which is further specifi ed in time and space Based on temporal context, what scenes will follow can be guessed; based on the context of space, for instance, the presence of objects can be guessed, etc (Atkinson et al., 1995 ) The described qualities of per-ception can make it easier for persons with low vision to perceive environment (for instance, the person can guess on what he/she should focus their visual attention ) Spatial context greatly assists to perceive individual details, but only if the person has enough sensations and information to use in the process of perception In con-trast , the tendency to perceive expected, not real, can cause errors in perception (Nakonečný, 1995 ) Therefore, it is important to lead persons with low vision dur-ing their education to the targeted verifi cation of vague perceptions through other control mechanisms

Synergy of perception is defi ned as the ability to perceive sensations through

more than one sensory analyser Then, the perception at a particular time is usually complex (a synthesis of sensations: visual, acoustic, olfactory, tactile, kinaesthetic) The inadequacy of visual sensation is often accompanied by sensations from other sensory receptors The use of the synergy of perception in various situations of daily living is the subject of learning and gaining experience (Jesenský, 2007 )

Social perception is defi ned as a characteristic intervention in the perception of the

world through the environment of culture in which it occurs Based on the experience

of recognition of other persons’ behaviour and their reactions and experiences, tation structures emerge which infl uence judgements for the next similar experience The evaluation of an impression becomes a basis for taking a certain position and a more or less adequate response The ability to understand social expressions is called social intelligence The reduced possibility of visual control of social situations is considered to be one of the major communication barriers 33 It is important to register the specifi cs of perception based on social communication in both its components: verbal and non-verbal Language names the perceived and allows its categorization

orien-On this basis, conceptual logical thinking is developed Through language and speech, the process of communication, mutual exchange of information and sharing of experi-ence occurs (Nakonečný, 1998 )

For persons with severe visual impairment, the use of language is irreplaceable compensation means; however, only provided that they can suffi ciently understand the content Linguistic means can support the creation of images of an object, the under-standing of ongoing processes and they can also help to understand the changes and limits of persons’ vision and learn how to effectively compensate for them (Galvas,

2002 ) However, to bring verbally acquired knowledge into precise and complex tionships (for instance, through learning) is a very demanding process The problem is not only knowledge as such but also the creation of most accurate real image which is necessary for the retention and recollection of an adequate response A partial or total unavailability of the perception of non-verbal components of communication affects the form, process and signifi cance of the message Unless persons with limited visual

rela-33 Similarly, sociological surveys also show that the fear of social communication is one of the most frequent causes of the limitation of human activities (Pluhařová, 1999 )

1 Visual Impairment and Its Impact on Development

perception can distinguish the non-verbal component of communication, they are at a serious disadvantage 34 Such a disadvantage can be partly compensated for by other available resources (body positions, dynamics of movement, etc.) The verbal compo-nents of speech can provide some orientation through melody, speed, phrasing speech, etc 35 The level of ability to use rehabilitation and compensation techniques in various types of social interaction depends on the level of social intelligence However, learn-ing can very much contribute to its improvement 36

1.5.1.2 Concentration of Attention

Attention is the cognitive function which enables to target consciousness in a particular direction and, at the same time, to exclude other possibilities There are two types of attention: overt and covert 37 From psychological perspective on the function of selection of stimuli, there are also other laws which can be quite differ-ent in case of limited visual perception One of the factors infl uencing the shift of

attention is the overall directivity of attention, which is generally associated with the

personal disposition of the individual and his/her emotional tuning So demand on the concentration of attention on stimuli from various sensory organs can differ

In case of persons with low vision, the diffi cult part is to attract attention

According to Vágnerová (2004, 45), ‘Attention is generally more easily attracted

by the stimuli which are new, at least partially understandable and which can meet some of the needs of the person’ It applies to persons with low vision that the atten-tion is primarily attracted by stimuli which are at least partially recognizable and understandable for visual perception Secondarily also other laws apply (the princi-ple of adhesion of attention to other than visual stimuli, especially if the other stimuli bring stronger sensations) In terms of demand for concentration, visual perception has the advantage that, in most cases, personal pace is respected However, the con-centration of attention on acoustic stimuli is more demanding as the listener has to concentrate in the very moment when the speaker is talking In case of persons with low vision, it is necessary to respect special needs and longer perception time

‘Attention is one of the regulatory mechanisms of human activity’ In the situations

of long-term mental stress, the quality of attention physiologically decreases 38

34 The most serious impact is in persons with congenital severe visual disorder; it is because of the diffi culty of building ideas about the importance of non-verbal communication in human speech

35 Reduced ability to perceive the non-verbal component of communication is in many cases also complicated by external causes The most common ones are: distance, mechanical barriers and too rapid succession of changes

36 One of the programmes of social rehabilitation of persons with low vision deals with strengthening competences in social and communication skills (Galvas, 2002 )

37 Another generally accepted theory of concentration of attention is LaBerge’s theory of tion circuit It assumes the existence of two paths of linking the cortex to another place: direct— informational and indirect—modulation paths (Kulišťák, 2011 )

triangula-38 Despite the fact that persons with low vision perform a number of activities based on experience (similarly to persons without visual impairment), demand on their attention is incomparably higher (due to imperfect visual perception , compensatory senses or synergy of both) (Jesenský, 1994 ) 1.5 Psychosocial Aspects of Visual Impairment

A training of selectivity and attentional directivity in various critical situations and activities can be effectively used in low vision rehabilitation and education (for instance, focus on the sensations facilitating orientation in the planned intention)

In case of children with low vision, training in synergy and deliberate selection of attention should be part of special education

1.5.1.3 Memory and Visual Learning

‘Memory enables the storage of information, which is a prerequisite for learning’ (Vágnerová, 2004, 61) The quality of visual information promotes the understand-ing of perceived, which is then refl ected in the quality of retention Thus, visual information is the most commonly used method of learning, both in case of inadver-tent and intentional learning In case of the education of persons with low vision, it

is necessary to start from the premise that memory is to be used to a much greater extent and with a higher degree of intentionality in order to achieve an effect com-parable to normally sighted persons An important requirement for special educa-tion and rehabilitation is to achieve the maximum effect of visual learning to create the most accurate visual perceptions and to use visual memory in the best possible way In the event that the conditions do not allow effective use of vision, the means

of substitution and compensation are used 40

1.5.2 Specifi cs of Adaptation and Coping

Theory of self-regulation by Carver and Scheier ( 1996 ) points at the vital role of fulfi lling long-term personal goals as one of the key indicators of quality of life

A signifi cant restriction or loss of vision can in most cases cause complications

39 Souček ( 1992 ) talks particularly about the visual type: the directivity of attention was focused for the large part of life primarily on visual attention

40 The issue was specifi cally addressed by Čálek, Holubář, and Cerha ( 1986 ), Langrová ( 2005 ), Vágnerová ( 1995 ), Požár ( 2000 )

1 Visual Impairment and Its Impact on Development