€¦ · Web viewstream, which is the “where is it” pathway. And that’s associated with the posterior parietal occipital lobe. ... prone to have an ischemic stroke,

Transcript: Understanding Cortical Visual Impairment (CVI)

HadleyUnderstanding Cortical Visual Impairment (CVI)Presented by Dr. Kia EldredDate October 21st, 2011

Billy BrookshireWelcome to Seminars@Hadley. My name is Billy Brookshire and I’ll be your Moderator today. And today we’re going to be talking about cortical visual impairment. Your presenter today is an incredible presenter on this topic, Dr. Kia Eldred, who has been presenting on cortical visual impairment for some time and is one of those experts in the field who knows a lot about it.

Kia and I worked for years; well I shouldn’t say that Kia should I? Worked for a few years on a medical program down in Houston and I always enjoyed her presentations as I know you are too. So that I don’t take any more of her time I’m going to go ahead Hadley.edu | 800.323.4238 Page 1 of 54

and relinquish this microphone. So Kia, I’m turning the microphone over to you.Dr. Kia EldredGood morning everyone. This is pretty exciting. I’ve never done anything like this on the internet, so new for me. I have known Billy a long time and I’m not embarrassed to say that; he’s a great guy and I’m getting older and I’m okay with that. So I’m going to talk about cortical visual impairment and blindness; talk about functional implications and rehabilitation.

I am an optometrist and I worked at the University of Houston for 20 years. And I’ve worked in the field of brain injury and acquired brain injury and worked with multiply handicapped kids all that time. I’m currently at the Michael E DeBakay VA Medical center in Houston. And there I work with low vision patients as well as the gentleman coming back from the most recent conflicts with concussive blast injuries and with stroke (inaudible 0:01:42) and a researcher.

Okay, so the course objectives that we’re going to be discussing are that you’ll be able to define

Hadley.edu | 800.323.4238 Page 2 of 54

cortical blindness and visual impairment and identify different types to recognize clinical findings and functional implications of cortical vision loss as well as strategies to enhance their vision. And you’ll understand less commonly seen cortical visual changes and the importance of rehabilitation and education will be emphasized.

Just a little, I have a slide up of my dad’s art work. His name was Dale Eldred. He worked in Kansas City for a long time so hey those of you in Kansas City. And just like to touch on his beautiful art work with rainbows.

The next slide I have up is the definition of cortical blindness and visual impairment; both congenital and acquired. And I know those of you that are taking this as CE, I wanted to tell you it can occur both congenitally and it can be acquired with many fewer cases that are acquired.

As far as vision loss in the United States, cortical visual impairment makes up 22% of children with vision loss in the US. Now that’s the majority of children who have visual impairment. There is 14%


of kids that have retinopathy of prematurity, which is actually sort of related. And then optic nerve hypoplasia is 10% and coloboma is 7% and cataract is 6%, Albinism is 5% and optic atrophy is 2%.

Cortical visual impairment is now the leading cause of visual impairment and blindness in children in the United States. And that’s probably related to the fact that we are able to see more and more kids that are being born quite early and with other types of issues and neurological and developmental difficulties. So it is associated with cerebral palsy, and that might be something that you want to remember if you’re taking attest in the near future.

General CVI diagnosis and evaluation – the way this diagnosis is come to is that we’re looking at it as a diagnosis of exclusion; it’s based on medical history information often. As an optometrist I don’t tend to be the one to give the very first diagnosis of this but I may do that because it may be that this has never been brought up but we’re seeing all the signs and no one’s put this label, if you will, on the child.


But it is a helpful label because it’s going to allow them to be looked at in a particular way and rehabilitated in a particular way. So it is a diagnosis of exclusion. I think that we’re going to find, as far as history would be, there would be a history of perinatal hypoxia and ischemia. There would be perhaps traumatic brain injury; encephalitis, meningitis. And about 75% have accompanying neurological deficits as has been noted in a recent study, which makes sense.

So, hypoxic ischemic encephalopathy would be an infant that would be a term infant that perhaps at birth had this difficulty. Periventricular leukomalacia, or PVL, would be a pre-term infant who has had an episode of lack of oxygen. And then TBI, or traumatic brain injury, would be a child that perhaps had “shaken baby”, accidental head injury, meningitis, shunt failure, seizures, cardiac arrest or development delay.

So all these children would be people that we’d be really concerned that may have a cortical visual


impairment and we’re going to be looking at that as we examine them.

So, the demographics of congenital CVI are were going to find it more commonly in wealthier nations; although a friend, an ophthalmologist I know Linda Lawrence in [Filana, Kansas] does travel extensively and really has found so many kids out there that have this diagnosis besides the US. But probably more predominantly in the wealthy nations due to our ability to medically intervene early in their lives.

And it’s considered to constitute between .07% and .22% of the total school population in the US. I think this is something that you’ll already probably acknowledge, but just kind of review this and to think about it because this is the area I know a lot of teachers and books that work with kids as far as mobility.

These are the things you start wondering about when you’re working with a child. And they may not have the label CVI, but you’re definitely seeing some of these signs. And do kind of ask about that


and perhaps they need further evaluation to determine that because it will help you work with them if you have that knowledge.

So this would be a child that perhaps has a unwanted or avoided social gaze; they just don’t look in your eyes as you speak with them. They have very brief fixations; an intermittent following of any objects. They often have, most of them will have reduced visual acuity but also there are some folks that have 20/20 vision and cortical visual problems.

And I really think; I have a child that was premature, I have triplets that are 13 and they were born at 29 weeks and one of my kiddos is pretty brilliant but has a really hard time with object finding and just some different issues that really are CVI related.

Visual field block is not uncommon with generalized constriction commonly. They may have an altitudinal defect, meaning they can’t see on the inferior or maybe the superior part of the visual field, or hemianopsia, meaning to the right or the


left, or field cut is what our medical colleagues often call this. This can be very difficult to test for if the child has cerebral palsy and is non-verbal.

But I work in the Nova clinic at the University of Houston and there are several other clinics like this in the US. We look at the child. We examine from fairly objective means what their vision is like. And over the years we’ve had pretty good success in determining what a vision field looks like based on just confrontation responses and we’ll talk about that.

These children have decreased responses to visual stimuli when there’s music, noise and sounds present and often when they’re touched; so they just can’t have simultaneous stimuli. They have to concentrate to use their vision. So there’s two different sorts of areas of vision that are disrupted with cortical visual impairment. There’s a dorsal stream, which is the “where is it” pathway. And that’s associated with the posterior parietal occipital lobe. And then there’s the visual motor disturbances that are occurring with that. So there’s two – visual motor and visual spatial disturbances.


There’s deficits in fixing direct visual attention to objects. This is why you also see that straight ahead gaze. They can often shift fixation and gaze to a new stimulus quickly and they have hard times with fine motor tasks like copying and drawing. And they may also have visual spatial disturbances such as finding objects, judging direction and distance objects, and orienting their body to the physical world. So they’re often standing too close to someone or can’t find (inaudible 0:09:34).

Then there’s the ventral visual system which is also disrupted, which can be disrupted with CVI. So it might be one or the other or both. So the ventral system is the “what is it” pathway. And this occurs in the inferior temporal lobe of the brain. These folks are going to have trouble with discrimination, recognizing objects and integrating visual images and objects.

So the team players for rehabilitation are going to be this list I have on the screen, which includes a physical medicine rehabilitation, physician. If the child doesn’t have any physical deficits, this person


probably won’t be coming into play, but if they have spasticity or other issues with motor movement then they’re going to be on the team. There might also be an orthopedic person.

The pediatrician, neurologist, physical therapist, occupational therapist, speech therapist, artificial therapist, if the patient is visually impaired an optometrist, orientation mobility specialist; these will all be folks working with the child as well as probably a recreational therapist.

Here’s a picture of a young lady, probably three or four. I think I lifted this from somewhere; it’s not actually my patient. But this is pretty commonly what we’ll see our kiddos look like. She’s in a wheelchair with a table on the front of it and she has a push button for probably yes or no answers. She is strapped in pretty well so she can be sitting upright. So they have a lot of motor problems and difficulties as well as communication difficulties. And they even have a fan up by her to maybe regulate her temperature, that may be a problem for this little girl.


So I’m going to talk about a case next and kind of apply what we’re talking about to the case. So, this is the case of a young man, one of my more favorite patients frankly, those are the ones you always remember well of course. And he is now 12; I started to see him when he was like I think five or six. And he was a 28 week old premature infant. When he was born he weighed about 1 pound 15 ounces; so he was a little bitty tike. He’s a twin and I sort have this multiple thing.

So he had central apnea, meaning he was having a difficult time with breathing but it wasn’t physical it was a central neurological deficit. He had autotoxicity from gentamicin, an antibiotic, as a preemie, which can happen. Se he has hearing loss, total hearing loss. He had cochlear implants at age three. He’s currently in good health. He is wheelchair bound like our little girl I showed in the picture.

He has a headrest because he cannot sustain erect head posture, which starts coming into play with a lot of these guys. He is a special education student, but it includes inclusion classes in sixth grade. He has also some resource and life skills that his


parents are very adamant about him being in inclusion; it’s been great for him.

He has occupational and physical and speech therapy at school as well as the visual imperative (inaudible 0:13:04) mobility services. He uses a DynaBox for communication and a Smart Board. And probably a lot of seeing this on your iPad and that’s become a really great thing for communication and it will be interesting to see if when he comes back in if that’s what he starts to use. He is not verbal, aside from the speaking with the DynaBox, but a very with it, interactive child.

So we utilize something called Cardiff Cards. Many of you are familiar with [Color Cards], which are cards that have stripes on one side and not on the other. The stripes change in width and they’re black and white. They start very large. You hold the cards up for the child to view and we see which side they’ll look; to the right or the left. The stripes fade into gray.

So after a while the stripes become too narrow for the child to discern the difference between the side


with the gray and the side with the black and white. So we’re able to measure the visual acuity by measuring the distance between the black and white stripe and the distance they are from the card. Just like on (inaudible 00:14:14), with the big E and our eye can see the separations; that’s what the [Color] Card does. It’s looking for the separation or the resolution of our eyes and our brain.

So this fellow, with preferential viewing is what we call it, because we were having the child look towards one side or the other of the target and show us with their eyes what they’re seeing. He got 20/40 acuity, which is about two lines from the bottom of the eye chart, three; so really quite good vision. His previous exams spanning the seven year time I was seeing him, he went from 21/30 all the way down to 20/40. And he is pretty accurate with his responses.

He has a 30^ alternating exotropia, meaning his eye turns out one at a time. He uses one eye at a time to view information in front of him. He has a vertical gait palsy, meaning his eyes do not move up and down. They’re only straight ahead. So he


had a deficit near the time of his birth where he had some kind of interruption in that track in his brain and his eyes only move horizontally.

He has pretty full visual skills, and I’m going to talk about that in a minute. There’s a picture of Cardiff Cards. Now what the Cardiff Cards look like, I don’t see it on my screen either, is that they are cards which have pictures, one on the top and one on the bottom. And what you’re doing is you’re looking at the separation of the black and the white. So there’s a picture of a fish on the top of one card and on the bottom of another and it’s black and white outline.

That one actually shrinks so that it’s harder to see and discern against the background of the gray as the visual acuity increases. But you’re just looking at the kiddo looking up and down. And for this guy, although he has this vertical gait palsy, we held the fish side to side and we would talk about the picture on the card. So these are a little more fun for kids than looking at stripes.


The next picture should be I think some toys. What we do with the toys, and I’ll just keep talking, is that we use these as targets for peripheral vision. We’ll stand in front of the patient and the other person or examiner will stand behind them and bring the targets in from the side. We use lights, we use toys, we look for the kiddos to move their eyes to the position where the object is coming.

Now with this fellow, the guy I was seeing, the one I’m discussing, he actually would smile. So he was able to communicate well enough and understand what we were requesting of him. That whenever he saw the target coming he would smile. And so you can do that, you can do eye blink, but a lot of our kiddos we just look for responses usually.

So as far as assessment of this child, he had normal color vision, which we’re going to show a picture of in a minute. And again, it’s a preferential viewing path. He had good contrast sensitivity with the Hiding Heidi cards, which are the pictures of one side has a face and one side is blank; and the side with the face gets more faded as we go further into the cards. He had a normal focusing or accommodated response. And that’s a really


important thing for these kiddos for us to look at is, their focusing for up close. Some of them have difficulty because of seizure medications and other problems and so we want to look at that closely.

He has a really small refractive error. He has a little bit of far-sightedness and some stigmatism in his eye, but his visual acuity is quite good and the command of his neuro work is quite high because he’s in these inclusion classes. So we want to take that into account and not just think about the refractive error.

People with cortical vision impairment can still benefit from glasses in optimizing the image on their retina. So we always want to think about correcting them with the best correction. In some cases the vision is so poor, as light perception or very poorly defined form perception, then we don’t want to mislead our parents and we’ll talk to them about it. There may be some reason to go ahead and put them into glasses even as a protective device.


So we did evaluate the ocular health and it was passed and everything looked fine. This is a Pease Allen viewing plate, which are not readily available, and this is what we used though. And there are some other preferential viewing tests available for color, not many really. These are just colors embedded in the background and that’s how we determine color, by him just looking at the little square on the purple background. There’s a green square on a purple background and a blue square on a purple background.

So what we did as far as a plan for this fellow is he would qualify for vision services. So because he has a cortical vision impairment he should still fall under the visually impaired category, even though he’s 20/40 and has fairly full fields, we want to make sure he gets at least a consultation on levels of vision. And positioning is really important for him. He can’t look up and down readily so we want to make sure things are straight ahead of him.

Color coding would be okay to use for education material. High contrast is not necessarily that important for him because he has pretty good color vision. Continuing contact lenses is actually a good


idea. So I did not fit him in these lenses; an outside practitioner saw him a few times and she fit him and then he started to come back to us and we continued to keep him in contacts. But his mom was really familiar with contacts and so she would just sit him on the floor, stick it in his eye and he was ready to go. And it worked well because of his head rest, he could not keep his head erect and the glasses would get in the way if he turned his head, they would knock off his ears.

We would recommend a viewing size of at least a quarter inch size material that’s 16 inches, or the normal working distance. We try to make things a larger threshold for their ability to just see items because we don’t want the child struggling to see everything just like any adult, same thing. We’re also going to have him come back in a year for an annual exam.

And he’s functioning pretty well in the classroom. There was a time when his peers were short, he was kind of elevated in his chair and was having a hard time seeing them because he couldn’t look down well enough. So we did try some prism on his glasses to see if that was help. So it wasn’t that


successful, but you do sometimes have to get a bit creative.

As far as adult cortical visual impairment, and there may be more of you interested in children, I don’t know what the ratio is out there. So when there’s a question about the difference in material sizes, or the sizes in material for the acuity, I have a rule of thumb and my rule of thumb is that if they have 2100 visual acuity the visual size would be about a quarter inch in size and 15 inches. And that’s about three to five times the threshold of what they can just…so that’s using a calculation.

And then up to 2200 they need about a half an inch, etc. So 2100 is one quarter inch and 2200 is one half inch. With adults I’ll often have them read and I’ll make a measurement and then they get it a few times larger in size so it’s not reading again at threshold.

Causes of adult cortical visual impairment – probably primary cortical visual impairment, I see it more often in cerebral vascular accidents or strokes. About 700,000 stokes per year in the US.


And the largest group of visual disorders after acquired brain injury are homonymous hemianopsia or field tests. About 20% - 30% of everyone that has a stroke actually has a visual field defect that they cannot feel.

And it should be noted that 40% of hemianoptic field defects recover after their stroke within the first two months. So, right during acute care of these stroke patients they’ll often have a resolution of the visual field block. With traumatic brain injury 85,000 people suffer from this as long term disability and in the US more than 5.3 million people live with this disability caused by traumatic brain injury, so there’s large numbers. And I don’t have a number on how many have visual field defects after that.

So as far as how we would determine if this is a cortical visual impairment – rely on MRI and CAT scan could be very helpful to indicate the locations of damage that would lead us to believe it’s a cortical visual impairment. There’s various levels of improvement in the visual field in visual acuity. If there’s total loss of vision it can resolve all the way back to 20/20 and normal field or they might have


some visual impairment still present after the cortical visual impairment. And I’m going to share a couple of cases.

Here’s the team that works with these folks – we would drop the pediatrician, dump the neurologist, probably internal medicine physician because they’re probably having other physical difficulties if they had had a stroke; OT/CLVT, optometrist and probably an orientation mobility specialist.

The most common vision loss of cortical changes is (inaudible 00:24:14) visual field. Less common is a bi-lateral occipital loss with near or total blindness. And I’ve seen I can’t even tell you how many, there’s not a lot of these types of patients over time. They usually have good eye alignment. They don’t have strabismus or other ocular disorders.

And some of these patients are really very interesting. I mean it’s very tragic, but patients that have Anton’s Syndrome who had perhaps had a stroke and lose all their vision, they may deny their vision loss. They may say “Oh I’m fine. I can see fine.” And they’re often very aware of color. So


they don’t have an emotional response because their brain has forgotten what vision is.

This is pretty hard for those of us in the vision field to imagine, but there’s this lack of grieving for the loss of vision because they don’t have a remembrance of vision. But they’re many times aware of colors and shapes. And some of these folks can navigate their environment despite their vision loss and this is called blind sight. Because in the secondary visual pathway there is…

So blind sight is due to the resistance of the extrastriate pathway for objects and spatial vision, which we already talked about. The ventral stream – the “what” pathway, and the dorsal stream – the “where” pathway.

So there have been some studies done with patients in the occipital lobe and they do provide evidence for some existence of the…there was a extrastriate study that demonstrated that the transient deficit was recovered in a matter of days and a relocation of the vision processing to another location in the brain. So we’re learning more and


more about this as we have more and more imaging available.

There’s another study that was done with 21 subjects with lesions that were older than a year. So these patients probably had strokes a year before that and they had a crossover design so this group got to have both therapies.

They did a standard vision restoration therapy. So they used this little point of light that would blink in the area of vision. And then they also did a study where they looked at the extrastriate vision restoration therapy. And they had a vision stimulus that activated the extrastriate pathway. So they were shining lights where they didn’t see anything.

With the extrastriate vision restorative therapy they had a massive moving spiral that would move in that area where they couldn’t see. So what they found is the way they looked at what kind of vision maybe they regained was that they used a high resolution perimeter, they used regular perimetry like the Humphrey Visual Field. They used the National Eye Institutes Visual Functional


Questionnaire. They try and use patients about a half hour every day with as large stimulus, spiraling (inaudible 0:27:04).

And the control group was trained with the standard VRT for the same kind of vision restorative therapy. So they found an improvement in detection performance, not a really large one, but 1.2% compared to the standard. So they were able to find some improvement in those blind areas and they think that it’s the magno-cellular pathway, there’s a direct connection from the LGN, the lateral (inaudible 00:27:29). And they’re looking at that now.

So this is that pathway that we don’t really acknowledge or unless maybe a person has no vision and can make their way around, that’s when you start to see this. So it doesn’t function so much (inaudible 00:27:47). But those that have cortical visual impairment seem to be able to use it.

So, I’m going to go through a couple of cases. This particular case was one of my Veteran’s, the next two cases are. And this fellow is 61 years old. And I


have to say that the acquired cases have taught me about my kiddos who can’t tell me about their vision. They can’t tell me things that are different. But these gentlemen and women will come in and be able to explain a little bit more about their vision.

He’s hypertensive and diabetic and he was admitted for progressively worsening headache and was prone to have an ischemic stroke, which converted to a hemorrhagic stroke. He had an angiogram and it showed complete occlusion of his left vertebral artery and he had visual loss in his eye and bi-lateral heminoxia.

And I have an angiogram shot here which I’m sure will take a while to come up, but it basically shows occlusion of an artery, total occlusion. So I don’t know that it’s that important. But on the angiogram on one side you’re looking at pictures of these little blood vessels. And on the left side of his brain you see this nice big blood vessel and on the right side there’s just nothing there, it’s pretty much gone. That’s totally occluded.


So you can tell that then the brain is not being nourished in the back part of his brain on the right side. So he reports that he has sort of peripheral vision that’s fuzzy. He said it’s sort of like an unfocused (inaudible 00:29:20) screen in the peripheral part of his vision. So he’s still got information out there that it was fuzzy.

He said he can see fine looking straight ahead. He can read short paragraphs without error. He said he wasn’t having any trouble with getting around. And he could participate in therapy, which is confirmed. And they recommended that he come and see us in the Low Vision Clinic. And the physician did tell him he couldn’t drive, which was a good choice.

So he came into see us. He reported that his vision had been improving, but it was still blurry. He couldn’t identify information directly in front of him, but his peripheral vision was getting better. he does have difficulty with the steps, especially stepping up, and he had a lot of glare problems.


His goals were to drive and read without it being so much effort to read. And so I’m showing pictures of his visual field, which is very impaired. He has this one little spot in his inferior left field of his left eye that seems available, but the right eye seems (inaudible 00:30:21). If you look at the screen where the front is it just shows a big black circle for each side.

And the Humphrey measure is just at the threshold of what the patient can see, so it can be a very difficult test. So it’s measuring just what they can just see. His distance vision was actually 20/20 on each side so he had that preserved central vision. Without any glasses on he saw at near 20/40, 20/30, but he was presbyopic so his glasses had improved. He had a really small prescription. His eyes looked straight. He had some difficulties with his lids but we told him how to take care of that.

Meibomian gland disease means probably dry eye symptoms. And then his next set of visual fields on a return visit – so that was his very first set of visual fields – and then the next set of visual fields which we did on him when he came to our clinic, because the others were from when he was in the


hospital, from October – now this is January, so it’s been about three months when he was seen – and you can see now there’s black circles but there’s certainly a large inferior area of light area where he is actually able to see down and to his left.

So it looks like he’s seeing just a small area, but like I said, this is threshold visual field testing. You can also see a little spot right in the middle of the visual field where he can see and that’s his 2/20 vision. And with gross confrontations this was really confirmed, that he really has this one small area. And this would be called a right homonymous hemianopsia with superior left quadrantanopia.

So we gave him new spectacles. We’re going to re-evaluate him on follow up with something called the Dynavision, and we did the reading evaluation and we did recommend no driving. And we also worked with his Meibomian gland problems. Then he came back. He lived quite far away and the things that we told him to do in the meantime would be things like playing Scrabble or doing Solitaire and working on doing scanning.


And the thing that we usually try to do is work with them on scanning types of activities so that they create a scanning pattern. And we’ll work with them on reading activities. And for him, he could read but it was very slow so we used line guides with him. He reports his vision is not the same but it improved more and is getting much better. So he’s really thinking he wants to drive now.

He has 20/20 distance vision and his visual field is, the far peripheral field looks pretty packed. Now I want to show you this next screen and I’ll describe it. I think we’ll finish after this case so you’ll be able to ask questions.

The next picture is another Humphrey visual field and it shows his visual field, there’s little black spots and little blank circles. So the dark spots are where he could not see, but he can actually see really far out in the periphery and then right in the center there’s a pericenter area, meaning just off the center, where he can’t see, almost like a doughnut.


So his far peripheral vision really improved in that three or two month period and then I did what is called a kinetic visual field, or visual field with a moving stimulus that’s about five millimeters in size. This is where he is looking at a target that’s not just a threshold. And you can see he now has this field in this inferior area on the left he sees, but on the right eye he can see a lot more in the inferior field.

And then when he uses both eyes together, which is the next slide, he’s regained quite a bit of vision. So he’s an interesting case just looking how his vision has improved over time. So he’s really, his visual field inferiorly and outside the periphery is pretty good, but he’s got these spots in the middle. And we have heard that with children, that they have sort of (inaudible 00:34:15) visual fields that we can’t really test on our patients that have acquired cortical visual impairment. This is where we can really tell that this happens as it returns or even if it just stays stable.

He did do the Pepper Test and his reading rate was pretty slow; he’s at 52.9 and then context [it equaled 6.5]. And then he did the DynaVision


which is a really good way to kind of see how people respond to the target by hitting this border of lights that pop on. And he got 135 total hits, or 1.77 average reaction time. And then less than 175 hits, which would be demonstrating some question about his driving ability. And certainly with those areas he can’t see centrally right around his central vision, we’d really have to watch him and see if he gets more improvement.

Billy BrookshireOkay. I had a quick question here. Michaela is saying “So the marked off area is where he can see?”

Dr. Kia EldredYes. So the area that was that big circle is where he could see. And as far as the extended – I actually went to about 183 horizontally and maybe 50 to 60 inferior and that’s really pretty normal edge of your visual field. But there’s probably spots inside there he’s not seeing.


So then there’s this next picture of the Dynavision, which is the board that has lights that pop on that are red and the patient has to reach out and touch it. So we can actually see how they use their vision and sight. Visual field tests, as you’re probably aware, they have to hold their eyes steady and not move their eye, but we know from working with lots of our patients that some of these folks are wonderful at moving their eyes and finding objects in space.

So I have another case, but I’m going to stop here because I want to take questions and I don’t think we have a ton of time left. Does that sound good Billy?

Billy BrookshireSounds good Kia. And it’s your presentation, so we’ll go however you want. We got a question here from Tammy that’s interesting, I thought you’d enjoy, on the chat room. And folks I’ll open up the microphone in just a few minutes, but I thought I’d take a couple from the chat room first. She says that she’s wondering if the part of the brain that


learns to read Braille is the same part of the brain that’s used when reading about sight.

She said she has a loved one who has normal high sight but due to high fever as a baby it damaged part of his brain. We were wondering if learning Braille would help him. He’s unable to read kindergarten level reading skill or write.

Dr. Kia EldredYou know, that’s a great question. We’re thinking reading of course has to do with the vision, but it has to do with the part of your brain that also uses language. So the part of our brain that looks at perception is our right parietal occipital area in temporal lobe. And then in the reading portion of our brain is on the left side.

So it really depends on did he have damage to that left side of his brain that would be causing problems. Because if that’s the case then it may still be hard to learn Braille because that’s the language area. And you know, tactile, I’m not sure where that falls because I really don’t work with tactile parts of the brain so much.


So I think that’s a great question, but I do think that if the left side of his brain was damaged where the (inaudible 00:37:36) area is, he may have difficulty with the reading skills; he may have alexia. So that’s probably a good question, but it would be worth pursuing that to determine if that could help him if he’s that visually impaired. Oh he has normal eyesight right? It may be hard. I don’t know.

That’s an interesting question. Because you know, our folks who have had these difficulties with reading it’s because of the brain damage. And usually we’ll basically have them work with auditory information at that point. And “can it be tested” – I see her question.

I think that way you’d have to do that is just try…well the people that I suggest to do the testing would be a neuropsychologist. They would be the one to do the test. You’d probably want to consult with a physical medicine rehabilitation doctor and have them look at the scans and determine if that’s what they think is going on.


Billy BrookshireWe’ve got another question up a ways Kia from Sherry. She wants to know if you can recommend a CVI specialist in the Northern Virginia or DC area, that’s where they live.

Dr. Kia EldredAnd this would be like an eye doctor that sees kids with this or adults with this?

Billy BrookshireIt is for her child. I can’t remember whether she said her son or daughter had CVI.

Dr. Kia EldredIn Washington, DC or Virginia…okay. I can’t off the top of my head but I can check that out. I’ll get back with you and then go from there. Does that sound good? You can get it to her Billy?


Billy BrookshireI can. And I’ll just Sherry, for you, if you’ll just, she just listed again. She said “My daughter has a genetic syndrome called…” – well you can read all that can’t you? But Sherry if you’ll just email me at [email protected] to remind me that I need to get the information to you, then I can pass it on.

Dr. Kia EldredAnd I’m jumping to my last slide which has my contact info and a picture of my family. So I have my email there. If y’all want to email me there that would be okay, to ask those kinds of questions.

Billy BrookshireWhat a good looking bunch. Okay guys I’m going to open up the microphone now for questions.

Dr. Kia EldredIt’s a good question. Should I just answer it off the chat Billy?

Billy Brookshire


mailto:[email protected]

Okay. Kia is going to go ahead and answer this question of the chat folks and then I’m going to open up the microphone again for anybody who’s got a microphone question. Go for it Kia.

Dr. Kia EldredOkay. So the question from Angela Greer is “Is optic nerve atrophy secondary to CVI?” That’s a great question. Yes. Many times it’s both the brain and the eye is involved. So what will happen is the brain will be damaged, and there’s something called retrograde degeneration, meaning the damage to the brain travels down through the vision system into the optic nerve. So we see it in the eye.

So although there are cases of optic nerve atrophy which are not connected to the brain, many times we will see children that have, or adults that the optic nerve that will look pale in color because they have damage now to the nerve. So it’s actually caused from the brain itself.


So the patient comes in and another doctor may say “Well they have optic atrophy”, but the source was actually because they had brain damage at birth. So they would be a CVI type of (inaudible 00:41:16).

That answers that question and I see there’s another question from Michaela [Avolera]. She said “I have a student that had brain cancer and has a hemianopsia, can she also have CVI?” And really, I think when we’re talking about CVI, I think anything that’s in the brain that causes a vision change is a CVI, cortical visual impairment. So if your patient has a hemianopsia, they had a cortical visual impairment and the brain cancer is what caused the change in the vision.

Now I will say that often vision hemianopsia’s don’t have this fluctuating vision, they would never have nystagmus; that would be the kids that acquired it prenatally. But technically I think that is a cortical visual impairment.

Billy Brookshire


Okay. Going to try opening up the microphone again folks for any questions back there. And Kelly, we’ll get back to your question shortly.

CallerOkay, I have a question. I wanted to clarify on asking the questions on the optic nerve atrophy being secondary to CVI. My husband was actually diagnosed with optic nerve atrophy sort of “of unknown origins”. His doctors think maybe it was caused by low levels of increased intracranial pressure over time. And then after the diagnosis of optic nerve atrophy we received a diagnosis of CVI basically just because the doctor said that with the way his vision was it was pretty evident that he had CVI because his vision does fluctuate.

So I’m just wondering are you saying the CVI comes first and that causes the optic nerve atrophy or is it just that there’s just brain damage which causes both CVI and optic nerve atrophy.

Billy Brookshire


Okay Kia, the question was which comes first basically. Does the CVI cause the optic nerve atrophy or does the brain damage come first and cause the CVI.

Dr. Kia EldredNo. The brain is damaged first and then it travels down the optic nerve. So yes, it’s the brain firsts and then the eye. And the eye is part of the brain, but it’s the brain itself that is damaged and then that goes down and you see it in the eye.

Billy BrookshireOkay. And we’ve got lot of good questions coming on here in the chat room. Do you want to attack some of those and then we’ll open the microphone up after you address these.

Dr. Kia EldredOkay. “Can CVI kids with hearing trouble do sign language”, I think is the question. And again, that starts becoming a question of perhaps the other side of the brain, you know, the language part of the brain. So every kid is really individual I would


say. I would say their vision probably wouldn’t stop them necessarily though, the fact that they have the CVI, they should still be able to do it depending on their level of visual acuity really. They could probably do their fingers.

And we know like Helen Keller learned to move her hands just from someone else moving their hand in her hands. So there is always some way to cognitively be able to try that, although some of the kids, their cognitive, they would be overloaded cognitively and they couldn’t do that.

And “Should CVI kids learn Braille?” I think that may be possible. A lot of them have cognitive developmental delays, so it might be rally difficult for them to learn Braille. And their tactile systems are probably still intact. So it all depends again on the kiddo. And we did have a little girl, the next question comes up about “optic nerve hypoplasia and CVI” – yes we see that combination sometimes. The optic nerve hypoplasia is probably in utero. It’s often caused by young moms giving birth, moms that are on alcohol or drugs, we see it with them, but not always. I mean it tends to occur.


And so yes, there are some kind neurological changes that have occurred and that caused the child to have the optic nerve hypoplasia, or the adult, but it can be interrelated. We don’t always see CVI with optic nerve hypoplasia, optic nerve hypoplasia occurs much more frequently and much less…

Billy BrookshireOkay folks I’m going to open up the microphone again to any questions that you might have. Julie we can hear you fine, but we can’t talk to you as long as you’re holding down the control key. So go ahead and ask your question. Julie you can ask if you want to.

CallerOkay, I thought I was asking my question. Sorry, I’m having some kind of difficulty. Can you hear me talking now? Okay. I am a vision rehabilitation therapist and I’m working with an adult with CVI who had a stroke back in May. And I’m going to be doing computer training with her because she’s trying to get back to work as a speech therapist.


And it’s very interesting because she can recognize objects on the computer, but not letters. And I’m just wondering are there people out there to consult with on teaching methods and whatever with adults with CVI.


Billy BrookshireOkay Kia, the question was Julie works with an adult who has CVI and was a speech therapist and she’s undergoing rehabilitation but has trouble recognizing letters. Julie was asking is there anybody who’s out there as a consultant or a teacher who might help somebody who needed help making the transition I guess.

Dr. Kia EldredWell you know, I had a patient like this and it was just heartbreaking because she wanted to go back to reading, and I think there was damage in the area of her recognition of letters. So it’s not the vision it’s the system for reading, meaning alexia versus simply vision, which is where it gets a bit tricky. I think again, neuropsychology may be the people that you call on to do the testing to determine that.

Because you want to know, you don’t want to give up hope, you don’t want to give up trying first, but there’s no one specifically that I know besides the neuropsychologist that would do that type of testing. So that’s kind of what I would recommend.


It can be so frustrating for those folks that are just trying hard.

Billy BrookshireSo do the neuropsychologist before you talk with somebody who might be able to do training then? Okay, we’ve got a question coming up in the chat room here from Patricia. She says she’s got a client that has a left eye retinal detachment; the other eye is diagnosed with a neurosympathetic blindness. Says he was a boxer and treated for head injuries and also has a diagnosis of visual field defect. Does he require an MIR for diagnosis of CVI?

Dr. Kia EldredNo. If he’s involved he would have already had one, he wouldn’t need another one necessarily. I mean, if he was being managed well medically I would think it would be okay. But knowing that he has a visual field defect from the head injury, I’m assuming not the retinal detachment, then he has the type of CVI from the standpoint of the visual impairment being caused by the head injury; that’s the visual field defect.


So it really, these are tricky cases because I think sometimes you wish everybody had an MRI but they’ve managed early and after the TBI they’ve gotten that MRI already done; so you don’t want to do extra testing unless it’s necessary.

Billy BrookshireAlright, thank Kia. And Julie wrote back and said she does have access to somebody who does vision therapy, she just wondered if there were other thing out there. So thanks Julie for passing that on. And I just realized Kia that we’ve gone two minutes over our time here and just because we were juggling a little bit at the start would you mind hanging in for another five minutes or so to see if there are any other questions anybody might want to ask?

Dr. Kia EldredNo. Not at all. Yeah and we have an LVT that’s working with us at the VA, with the VA patients.

Billy Brookshire


Let me open up the microphone one more time folks to see if anybody out there’s got a question they’d like to ask.

Dr. Kia Eldred…comment that came up and I saw this coming up earlier, can I address that Billy?

Billy BrookshireOh please do.

Dr. Kia EldredOkay, this is controversial what I said, and I apologize because I agree and I know people even in my own family that have optic nerve hypoplasia, but there’s a report that having no known cause, which is true, we don’t sometimes know why people have it, and there is more frequency of optic nerve hypoplasia in certain demographics like young mothers or in some instances from drug and alcohol abuse. But it’s important when we talk about optic nerve hypoplasia there’s a distinction because some patients, I mean there’s no known cause.


I think the general public has no idea about that and I think that maybe in the vision community we have some idea, but yeah, I would hope no one, even if this person’s parent has some kind of drug or alcohol abuse problem or whatever discriminate against that person. So I strongly agree, because I even have family members that have this.

But anyway, those are important things and I think those are important things for us to be concerned about with our patients. I’m not one of those people that doesn’t thing about beyond the eye. I really want to work with these people, to help them, and that’s why I wanted to offer this information. So thank you, because I think it’s so important for us to be sensitive to the folks we work with and the issues we’re working with and to not allow them to be discriminated against.

Okay. I just wanted to mention that.


Billy BrookshireThat’s a good one Kia, thank you. And I think we’ve gone five minutes over now so I’m going to go ahead and call it a day. I really enjoyed the presentation Kia. Sorry about the technical issues up front but I thought you handled that really well.

Dr. Kia EldredGood. I appreciate you asking me to speak and thank you all so much for coming on. It was a pleasure and hopefully this was helpful.

Billy BrookshireFor all of you I want to remind you that this seminar, like all of our seminars is archived and it’s on our website. You can reach it under “access past seminars” off of the opening home webpage for Hadley. They’re available 24/7, 365; you can download them or listen to them real time. So they’re always there. The Power Point will be archived along with the seminars, so by all means check them out.


I’ve got a few Hadley related courses you might want to check out. Hadley has a course in the human eye that’s just absolutely wonderful that tells you a lot about the human eye. Another one on macular degeneration and another on glaucoma for those of you who are interested in eye anomalies.

Again, just thank you all for participating today. As you know we value your feedback and please let us know what you thought about this seminar and if you have suggestions for future topics we’d love to hear them. Just send us an email at [email protected]. That’s [email protected] and that will help us determine what comes down the road and also how we can help you better.

Kia, any other farewell words you’d like to share?

Dr. Kia EldredNo. I really appreciate – the chat room’s going crazy and I might jump in there and talk to some people too. There’s some great comments. Y’all are a great audience. Thank you so much.




Billy BrookshireIf you’ve got one you want to answer right now by all means go for it.

Dr. Kia EldredThere’s some questions about if optic nerve hypoplasia improves and I think that’s true with development of the child as well as CVI; there’s definitely been studies that show, and personal experience shows that these kids often get better as they learn more and they improve developmentally.

And yes, whoever this Gina is that’s doing this paper for her graduate class, I’m happy to talk to her about some questions. That’s great.

Billy BrookshireThanks Kia. And you’ve got your contact information there so [email protected] folks if you want to contact Kia and ask questions. For those of you who are looking for CE hours, I’ve got some more information here so let me share this with



you. If you want to earn continuing education hours you need a separate registration and payment process. And you can find the link for that in the section called “earn continuing education hours” on the seminar page.

It will give you the instruction about how to log on to the quiz. Or actually, that will be given to you by email once you’ve completed your registration. Also, I guess you know that when a seminar is passed you can still apply for CE. All you’ve got to do is go and listen to the seminar, do the application process again and take the test. So you can do this for all the closed seminars later on if you want to.

Today the quiz is going to be open about 15 minutes after we finish the seminar. You get two tries per registration to get a passing grade of 70%. If you fail it twice folks, unfortunately you have to re-register and pay again. It’s a mean world isn’t it? You’ve got seven days from your first failed attempt to try again, but once you pass it folks you get a certificate that’s issued electronically right after you do a short survey and evaluation.


So don’t be shy. Get in there and get your CE’s if you need them. Last thing I need to share with you is that if you ever have tech problems, like some of you were having today, and we have sometimes, we do have a help desk. And you can reach them at [email protected]. That’s [email protected]. You can contact them any time. And folks, like Alan who’s on the call here with us today, will be glad to help you out with whatever is going on.

And also, if you’ve just got a general inquiry about courses or anything related to Hadley, you can get that at [email protected]. That’s [email protected]. We want to thank you all for participating today. It’s just been wonderful that you could all be here. And Kia, your presentation was absolutely great as it always is, always learn about 10 times more than my head will absorb. But I just learned a lot of things today as always.

I want to thank you for that and for sharing so freely with all these folks. Take care of yourselves folks. We’ll see you next time.






[End of Audio – 0:56:40]


Documents

€¦ · Web viewstream, which is the “where is it” pathway. And that’s associated with the posterior parietal occipital lobe. ... prone to have an ischemic stroke,