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Usher Syndrome
Visual Field

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Date: _______________________________________
Name of Child: ______________________________
Birth Date: __________________________________
Completed by: _______________________________

Procedure:
The examiner should face the student and have the student cover one eye with his or her hand. After giving instructions to look straight ahead at the examiner's nose, the examiner holds one or two finders up off the side (within his or her own visual field). The student is then asked whether he or she can see one or two fingers. This is repeated on the other side. If the student is able to discriminate between one or two fingers, using the examiner's field of vision as a standard, it is evident that there is not a significant loss of visual field. Each eye should be tested individually, as there might be a loss difference in each eye.

Results:
Peripheral Discrimination:
_____ Left eye
_____ Right eye