Vision in OT Practice

Housekeeping while people arrive.

Materials to have ready:

• Participation & Reflection Guide (printed or on screen)

Read the filed learning objectives verbatim — this is the AOTA-approved wording.

Objectives:

• Differentiate the levels of a structured visual performance framework and explain how each level influences occupational performance across pediatric and adult practice settings.

Explain how the session runs.

Schedule:

• Seven modules, 3.0 contact hours total

Transition: "OT Scope in Vision: What We Own, What We Refer."

Open here. "OT Scope in Vision." What we own, what we refer, and the language that keeps us inside our license.

Say why this section matters for their caseload, then advance.

Ask the poll: "When a teacher says "she can't track," what stops you from acting on it today?"

Options:

• I am not sure it is inside OT scope

Frame the slide: "Vision is a client factor, not a specialty add-on."

Walk each point, one sentence each:

• OTPF-4 lists visual functions among sensory body functions that shape occupational performance.

Contrast the two columns: OT owns (performance) versus Refer out (ocular/medical).

OT owns (performance):

• Observed gaze control during a reading task

Frame the slide: "Say this, not that."

Walk each point, one sentence each:

• "Loses place 6 times in a 2-minute passage" — not "has a tracking disorder."

Frame the slide: "Prevalence and the case for OT screening."

Walk each point, one sentence each:

• An estimated 1 in 4 school-age children has an undiagnosed vision problem (Kleinstein et al., 2003, population-based cohort).

Contrast the two columns: Term versus What it means in schoolwork.

Term:

• Convergence

Frame the slide: "Diagnoses OTs should recognize but never assign."

Walk each point, one sentence each:

• Cerebral/cortical visual impairment (CVI) — a brain-based visual processing impairment, not an eye finding.

Read the quote verbatim, then pause.

"A child can pass a 20/20 acuity screen and still be unable to read a page." — Why the acuity floor is only the first of five levels

Then say what it means for practice in one sentence.

Frame the slide: "Vision work already lives in your school day."

Walk each point, one sentence each:

• Board-to-desk copying, worksheet completion, and sustained silent reading.

Frame the slide: "Same-day referral triggers."

Walk each point, one sentence each:

• Eye pain, redness, discharge, or photophobia.

Read the scenario aloud, slowly:

A Grade 4 student squints at the board, holds worksheets at 15 cm, and reports headaches after the second reading block.

Then put these questions to the room:

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Screenshot of a de-identified present-level statement written in performance language..

Describe what belongs here: Photo showing habitual working distance, head tilt, or lighting conditions..

Contrast the two columns: Diagnosed and managed → OT addresses the functional limitation versus Undiagnosed, unverified, or changing → refer.

Diagnosed and managed → OT addresses the functional limitation:

• Low acuity: magnification, enlarged print, working distance, seating, decluttered materials.

Talk over the visual: "Two lanes, one student."

Say the caption in your own words: Medical eye care owns diagnosis and the optical correction; OT owns performance inside real occupations. The referral and the task modification run in parallel, on the same day.

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Land the "so what": If you stop treating while you wait on an eye-care report, the student loses weeks of instruction for a decision you were never going to make.

Explain the mechanism plainly: Diagnosis belongs to eye care; occupational performance under a known visual condition belongs to OT. Those two lines run in parallel, not in sequence.

Then give them the moves — say each one as something they can do Monday:

Two-minute case. Read it aloud:

A Grade 2 teacher tells you a student "definitely has convergence insufficiency — she sees double when she reads." Nothing in the file supports a diagnosis and there is no eye-care report.

Put the question to them: "What do you write, and what do you do first?" Give 60 seconds, no talking.

Reflection prompt: "Recall one referral that arrived with a visual complaint. Which part of it did you own as OT, and which part needed eye care?"

Cues:

• Name the occupation that was breaking down.

Knowledge check: "A student works at 15 cm from the page, squints during board copy, and reports headaches. Which statement belongs in your OT report?"

Options:

• Student demonstrates convergence insufficiency affecting near work.

Transition: "A Structured, Level-Based Visual Performance Framework for Clinical Reasoning."

Open here. "The Five-Level Visual Performance Framework." A developmental hierarchy that organizes observation, assessment, and intervention.

Say why this section matters for their caseload, then advance.

Ask the poll: "Which framework levels do your current goals most often target?"

Options:

• Level 1 — acuity and sensory access

Talk over the visual: "Beyond 20/20 — the Visual Performance System™."

Say the caption in your own words: Level 1 Visual Access → Level 2 Visual Efficiency → Level 3 Visual Processing → Level 4 Visual-Motor Integration → Level 5 Functional Integration.

Frame the slide: "Visual development milestones OTs should know."

Walk each point, one sentence each:

• Basic eye movement control (fixation, following) is commonly described as established by 2–3 months of age.

Contrast the two columns: Ventral / parvocellular ("what" pathway) versus Dorsal / magnocellular ("where" pathway).

Ventral / parvocellular ("what" pathway):

• Carries fine detail, color, and form for object and letter identification

Talk over the visual: "Vision's two highways in the school day."

Say the caption in your own words: Ventral "what" signs versus dorsal "where" signs, side by side with the classroom behaviors each one produces.

Frame the slide: "How the Five-Level Framework was built."

Walk each point, one sentence each:

• OTPF-4 names visual functions as client factors — the framework simply organizes them by the order they have to be stable in.

Talk over the visual: "One example per level."

Say the caption in your own words: What you see, the probe that confirms it, and the OT move that follows — for all five levels.

Run the five levels bottom-up.

Name each level, then say which one you assess first and why.

Contrast the two columns: Functional signs versus OT direction — adapt and refer.

Functional signs:

• Print held very close or pushed away; head tilt

Talk over the visual: "Access, before and after."

Say the caption in your own words: The same worksheet at photocopy contrast and at full contrast with larger print — the gain came from the page, not the student.

Contrast the two columns: Functional signs versus OT direction — remediate + support.

Functional signs:

• Loses place, re-reads, finger-tracks past expected age

Talk over the visual: "Line loss and the stamina curve."

Say the caption in your own words: Place-keeping errors across a 2-minute passage, and accuracy decaying past minute 8 — an efficiency signature, not inattention.

Talk over the visual: "Oculomotor control — the movement systems."

Say the caption in your own words: Fixation, smooth pursuits, and saccades carry reading and copying. When they fatigue, accuracy decays on a predictable curve — the classroom signs and the OT directions, side by side.

Contrast the two columns: Functional signs versus OT direction — load, then strategy.

Functional signs:

• Cannot find the item on a busy page or crowded hook rack

Talk over the visual: "Visual load on the page."

Say the caption in your own words: Same target item on a crowded page and a de-loaded page with a taught search pattern: 41 seconds with prompts vs. 7 seconds without.

Talk over the visual: "Perception — and what it looks like in handwriting."

Say the caption in your own words: Discrimination, visual memory, spatial relations, and figure-ground — and how each one surfaces on the page as placement, orientation, sizing, and spacing errors.

Contrast the two columns: Functional signs versus OT direction — isolate, then treat.

Functional signs:

• Legible in isolation, degrades under speed or volume

Talk over the visual: "Trace vs. copy vs. dictation."

Say the caption in your own words: Three writing samples of the same sentence. Clean dictation with a poor copy points upstream — treat Levels 1–3 before drilling the hand.

Talk over the visual: "When the eyes and hand stop agreeing."

Say the caption in your own words: The trace–copy–dictation comparison at a glance, with the functional signs and the clinical rule that keeps you from drilling the hand for an eye problem.

Contrast the two columns: Functional signs versus OT direction — measure the occupation.

Functional signs:

• Reading rate and endurance below expectation

Talk over the visual: "Where the goal line sits."

Say the caption in your own words: Baseline and 9-week re-probe on the occupations themselves: sustained reading minutes, sentences copied, written output, and work completion.

Frame the slide: "Two rules for choosing where to start."

Walk each point, one sentence each:

• Bottom-up to stabilize: adapt or fix the lowest unstable floor first.

Talk over the visual: "The Active OT Remediation Pathway."

Say the caption in your own words: Medical clearance is the floor; the five levels climb from Visual Access through Functional Integration. Remediate the unstable floor on one side, compensate on the occupation on the other.

Frame the slide: "The same four-part shape, every level."

Walk each point, one sentence each:

• 1 — Baseline probe: re-measure the same task before you treat.

Contrast the two columns: Level 1 — Access versus Level 2 — Efficiency.

Level 1 — Access:

• Contrast and print-size trials, not drills

Contrast the two columns: Levels 3–4 versus Level 5.

Levels 3–4:

• Stress one processing skill inside a real page

Contrast the two columns: Levels 1–2 versus Levels 3–5.

Levels 1–2:

• L1: Fast Screener acuity/contrast; VPA ladders at 60 cm and 40 cm; printable cards in the Worksheet Print Hub

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Your own framework graphic, if you want it in place of the built-in ladder slide..

Describe what belongs here: Interactive activity or worksheet that demonstrates work at one specific level..

Land the "so what": Most "visual processing" referrals resolve one or two levels lower — the signal was not getting in, or the eyes were not staying on the work long enough to process anything.

Explain the mechanism plainly: The five levels are ordered by dependency: acuity and sensory input, efficiency, processing, visual-motor integration, functional integration.

Then give them the moves — say each one as something they can do Monday:

Two-minute case. Read it aloud:

A Grade 3 student reverses letters, loses his place, and rubs his eyes after five minutes of reading. The teacher asks for "visual perceptual therapy."

Put the question to them: "Which level do you investigate first, and what does that change on Monday?" Give 60 seconds, no talking.

Reflection prompt: "Take one student. Which level is the lowest one showing a breakdown, and what observable behavior tells you that?"

Cues:

• Start at the bottom of the ladder, not at the complaint.

Knowledge check: "A student copies inaccurately from the board and loses his place mid-line. Where should intervention planning begin?"

Options:

• Level 4, because the written output is inaccurate

Transition: "Screening vs. Assessment: The OT's Two-Step Workflow."

Open here. "Screening vs. Assessment." The OT two-step workflow: rule in the need, then measure it.

Say why this section matters for their caseload, then advance.

Ask the poll: "What happens in your setting after a vision screen flags a concern?"

Options:

• We move straight to intervention

Contrast the two columns: Screening versus Assessment.

Screening:

• Fast, caseload-scale, pass/flag

Frame the slide: "The two-step in practice."

Walk each point, one sentence each:

• Step 1 — Screen: brief probes at each of the five levels; record flags, not diagnoses.

Talk over the visual: "Fast Screener mid-administration."

Say the caption in your own words: Evaluator script, PASS/FLAG rubric, referral triggers, and the on-screen worksheet in a single view.

Frame the slide: "What VML gives you at the screening step."

Walk each point, one sentence each:

• Fast Screener — brief acuity, contrast, efficiency, and a functional writing sample.

Frame the slide: "What turns a flag into a Full VPA™."

Walk each point, one sentence each:

• Any probe failed at or below the expected level for the age band.

Contrast the two columns: Measure it versus Record it.

Measure it:

• Intermediate tasks at 60 cm, near tasks at 40 cm

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Capture the Say/Do card, level ladder, and scoring panel together..

Describe what belongs here: Photo of measured working distance, lighting, and seating during a screen..

Land the "so what": A screening tells you where to send the student next. It never produces a score you can put in a present level.

Explain the mechanism plainly: Screening is sensitive by design and cannot separate a capacity limit from a demand mismatch. Assessment does that, under controlled setup.

Then give them the moves — say each one as something they can do Monday:

Set up the contrast: "Postural setup changes what you are measuring."

Point at the before panel first. Feet unsupported, trunk collapsed, page about 15 cm from the eyes.

Then the after panel. Feet supported, hips back, page raised toward a slant, working distance near Harmon distance.

Two-minute case. Read it aloud:

A Grade 5 student passed the school nurse vision screening in September. In November he holds his book at 12 cm, closes one eye during reading, and has fallen behind on written output.

Put the question to them: "What is your next step, and why is the passed screening not the answer?" Give 60 seconds, no talking.

Reflection prompt: "Write the decision rule you will use to move a student from screening to full assessment. Be specific enough that a colleague could apply it."

Offer the sentence starter: "I move to a full assessment when... The threshold is... The evidence I need is..."

Think for one minute, write, then take two shares.

Knowledge check: "What is the job of a screen?"

Options:

• To measure the size of the deficit

Transition: "IEPs, Medicaid, and Occupation-Based Documentation."

Open here. "IEPs, Medicaid, and Functional Documentation." Turning visual performance findings into defensible educational relevance.

Say why this section matters for their caseload, then advance.

Ask the poll: "What most often gets your vision-related goals pushed back?"

Options:

• Educational relevance is questioned

Frame the slide: "What a reviewer needs to see."

Walk each point, one sentence each:

• The occupation: what the student is expected to do in the school day.

Frame the slide: "Occupation-based goals, not skill-drill goals."

Walk each point, one sentence each:

• Target the occupation: copying, sustained reading, worksheet completion, note-taking.

Read the scenario aloud, slowly:

Grade 3 student: near copying accuracy 92% for the first 3 minutes, dropping to 58% by minute 9, with 7 place-loss events. Acuity screen passed.

Then put these questions to the room:

Contrast the two columns: Reviewer accepts versus Reviewer questions.

Reviewer accepts:

• Copy accuracy falls 34% within one class period

Frame the slide: "What has to be in the note."

Walk each point, one sentence each:

• Skilled reasoning: why an OT was required for this session.

Frame the slide: "Write accommodations from measured conditions."

Walk each point, one sentence each:

• Only list a modification you tested and recorded a change from.

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: De-identified IEP text showing the present level and matching annual goal..

Describe what belongs here: Baseline vs. re-probe data used to document progress..

Land the "so what": If the present level does not name the occupation, the condition, and the measurable demand, the service does not get funded and the goal does not get taught.

Explain the mechanism plainly: IEP teams and Medicaid reviewers cannot act on "poor visual skills." They act on observable performance under stated conditions.

Then give them the moves — say each one as something they can do Monday:

Set up the contrast: "Before / after: the same student, two present levels."

Point at the before panel first. Reads as a diagnosis, cannot be measured, names no occupation.

Then the after panel. Observation, condition, and measurable classroom demand.

Two-minute case. Read it aloud:

A draft IEP present level reads: "Student demonstrates poor visual tracking and visual perceptual weakness affecting academics."

Put the question to them: "Rewrite it in one sentence you could defend in a Medicaid audit." Give 60 seconds, no talking.

Reflection prompt: "Draft one goal now: name the occupation, the visual performance factor limiting it, the condition, and the criterion."

Cues:

• All four elements, one sentence.

Knowledge check: "Which element is missing? "Student will improve visual tracking to 80% accuracy.""

Options:

• The criterion

Transition: "Case Walkthroughs: Three Common Occupational Performance Patterns."

Open here. "Case Walkthroughs." Four real student profiles, worked through together — then one on your own.

Say why this section matters for their caseload, then advance.

Ask the poll: "Which of these three presentations shows up most on your caseload?"

Options:

• Board copying breaks down, near work is fine

Read the scenario aloud, slowly:

Maya, age 8, has glasses worn consistently and a current eye exam. She copies the first two lines from her worksheet accurately, then loses her place, skips lines, and stops after 5 minutes. Her teacher says the first problems on a math page are always her best work.

Then put these questions to the room:

Read the scenario aloud, slowly:

Elijah, age 7, tracks smoothly, keeps his place while reading, and has 20/20 corrected acuity. His letters vary in size, drift above and below the line, and spacing collapses when he copies from the board.

Then put these questions to the room:

Read the scenario aloud, slowly:

Aiden, age 10, scores low on every task you present. He was up late, has no eye exam on file, and his teacher reports he "gives up on everything," not just visual work.

Then put these questions to the room:

Read the scenario aloud, slowly:

Sofia, age 14, reads at grade rate with clean acuity and efficiency. She cannot find a labeled part on a diagram, loses items in a full locker, and misreads graphs in science.

Then put these questions to the room:

Read the scenario aloud, slowly:

Noah, age 5, holds books about 4 inches from his face, squints at the whiteboard, and has a documented diagnosis of albinism with reduced acuity managed by his ophthalmologist. He engages well and works hard for 15 minutes at a time.

Then put these questions to the room:

Frame the slide: "How to read any profile in four steps."

Walk each point, one sentence each:

• Rule out validity threats: setup, state, effort, correction.

Contrast the two columns: OT acts versus OT routes out.

OT acts:

• Direct service on the unstable floor

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Profile chart from a completed VPA™ showing the shape you are discussing..

Describe what belongs here: De-identified handwriting or copy sample that illustrates the case..

Land the "so what": Three patterns cover most school referrals — near endurance, page navigation, and visual-motor output. Recognizing the pattern gets you to the right first probe in minutes.

Explain the mechanism plainly: Each pattern has a different latency signature: minutes to fatigue, loss across lines, or breakdown as motor precision rises.

Then give them the moves — say each one as something they can do Monday:

Two-minute case. Read it aloud:

A Grade 4 student starts written work strongly, then within six minutes his letter size grows, spacing collapses, and he asks to take a break.

Put the question to them: "Which pattern is this, and what is your first probe?" Give 60 seconds, no talking.

Reflection prompt: "For the vignette we just worked, what would you have done differently before today, and what will you do now?"

Offer the sentence starter: "Before today I would have... Now I will..."

Think for one minute, write, then take two shares.

Knowledge check: "Reading endurance collapses after four minutes but single-word accuracy is intact. What does that pattern point to first?"

Options:

• Visual processing (Level 3)

Transition: "Evidence Base, Levels of Evidence, and Selecting Graded Intervention."

Open here. "Who Does What — Supports, Roles, and Collaboration." Turning one flagged level into a plan the whole team can carry, and saying honestly what it rests on.

Say why this section matters for their caseload, then advance.

Ask the poll: "When you choose a vision-related strategy, what usually decides it?"

Options:

• Published evidence for that strategy

Frame the slide: "Vision is already inside the OT domain."

Walk each point, one sentence each:

• We describe vision as a client factor: acuity, field, eye-movement control, focusing, perception.

Frame the slide: "Four tiers, four owners."

Walk each point, one sentence each:

• Prevention is classroom design — the teacher and team own it; we suggest and model it.

Frame the slide: "Design first, accommodate second, treat third."

Walk each point, one sentence each:

• Universal Design for Learning simply means: build the room so fewer students need a fix.

Run the five levels bottom-up.

Name each level, then say which one you assess first and why.

Frame the slide: "One question you ask, one thing you hand back."

Walk each point, one sentence each:

• Teacher: when does the work fall apart? Give two changes to try tomorrow, in writing.

Frame the slide: "Teaching the team is part of the treatment."

Walk each point, one sentence each:

• A 10-minute in-service beats a 3-page email nobody opens.

Read the scenario aloud, slowly:

Maya writes legibly for about five minutes, then letter size and spacing fall apart. Copying from the board, she skips lines and asks her neighbor where they are. Eye exam last year was normal. Level 2 (efficiency) and Level 4 (visual-motor) flagged.

Then put these questions to the room:

Read the scenario aloud, slowly:

Devon reads fine for a paragraph, then rubs his eyes and stops. He says the words "go blurry" late in the period. No eye exam on file for three years.

Then put these questions to the room:

Frame the slide: "Say plainly what your plan rests on."

Walk each point, one sentence each:

• Strongest support: practicing the actual occupation — reading, writing, the real task.

Frame the slide: "Three quick checks."

Walk each point, one sentence each:

• Does this activity load the level that is actually unstable?

Contrast the two columns: Increase visibility / Enhance versus Augment / Substitute.

Increase visibility / Enhance:

• Increase visibility: more light, higher contrast, bigger target, less clutter — an 18 pt high-contrast worksheet at a glare-free desk.

Frame the slide: "The classroom modification set."

Walk each point, one sentence each:

• Lighting: even light on the task; never backlight the student.

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Screenshot from the VML Treatment Templates showing LTG/STO and dosage..

Land the "so what": Choosing the right activity and delivering it two minutes a week produces the same result as choosing the wrong one.

Explain the mechanism plainly: The evidence base for visual-performance intervention is dosage-sensitive; FITT-P gives you frequency, intensity, time, type, and progression to write into the plan.

Then give them the moves — say each one as something they can do Monday:

Two-minute case. Read it aloud:

A team asks you to add a visual-efficiency activity to a student's plan. You see the student once every two weeks for 30 minutes.

Put the question to them: "How do you make this dosage-honest?" Give 60 seconds, no talking.

Reflection prompt: "Name one strategy you use weekly. What level of evidence supports it, and how would you justify it in a meeting?"

Offer the sentence starter: "I use [strategy] for [level]. The evidence is... In a meeting I would say..."

Think for one minute, write, then take two shares.

Knowledge check: "What makes an environmental adaptation defensible in documentation?"

Options:

• It is inexpensive and easy to implement

Transition: "Competency Wrap-Up and Post-Course Examination."

Open here. "Competency Wrap-Up." What you should be able to do before the post-course examination.

Say why this section matters for their caseload, then advance.

Frame the slide: "Self-check before the exam."

Walk each point, one sentence each:

• State the OT scope line for vision in one sentence, without hedging.