97-2003 ppt american conference on pediatric cerebral visual impairment

A National Conference onThe Evaluation and Treatment of Pediatric Cerebral Visual Impairment The Children’s Hospital and Medical Center of Omaha, NE

Dominick M. Maino, O.D., M.Ed., F.A.A.O.

Professor, Pediatrics/Binocular Vision Service

Illinois College of OptometryIllinois Eye Institute

3241 S. Michigan Ave. Chicago, Il. 60616312-949-7280 (Voice) 312-949-7358 (fax)

[email protected] www.ico.edu LyonsFamilyEyeCare.com MainosMemos.blogspot.com

The Child with Special NeedsA Brief Overview

The Patient with Special Needs

Individuals with Special Needs

Cerebral Palsy AutismDown Syndrome Intellectual DisabilityFragile X Syndrome Brain InjuryPsychiatric Illness ….and….

Pediatric Cerebral Visual Impairment


• 1. Defining Pediatric Cerebral Visual Impairment

• Definition confusing, misunderstood and imprecise. • Pediatric Cerebral Visual Impairment (PCVI). • Pediatric Cortical Visual Impairment • Delayed Visual Development


•North America•Cortical Visual Impairment

•Elsewhere•Cerebral Visual Impairment


•History of CVI•Brain injury 19th century with Phineas P. Gage


• World War I, wounded veterans with brain injury

•Displayed perceived motion in the “blind, non-seeing” visual field.

•Ability to sense motion, lights, and colors

•Conscious or subconscious.


•Statokinetic dissociation (in children)• greater reduction in sensitivity to stationary visual

stimuli relative to similar targets in motion

•Riddoch phenomenon (adults)• Ability to sense movement even though blind

• “See” moving objects…but not stationary ones

• Blindsight

•Ability to ‘sense’ objects in the way


•Statokinetic dissociation (in children)

• Movement in the peripheral visual field may elicit a smile in the blind child with quadraplegia and profound intellectual disability.

• Children who are fed with a spoon may intermittently open their mouths to receive food when the spoon is moved in an arc from the peripheral visual fields, but not when it approaches the mouth from straight ahead.


•Statokinetic dissociation (in children)

• For those children who understand language stating what is being seen as the child reacts to it may enhance both visual and language development.

• Such children may rock to and fro. Whether this generates an image is difficult to know.

• Rarely, children with cerebral blindness who are mobile move slowly around obstacles. This phenomenon has been called travel vision.


• 1980’s adults with bilateral occipital cortex insult (cortical blindness)

•Term applied to children.

•Cortical visual impairment used in the 1980’s onward

• Definition of CVI includes injury lateral geniculate nucleus/visual cortex


•Reduced visual acuity identifying feature.

•Many children damage to white matter surrounding the ventricals (perventricular leukomalacia PVL)

•Cerebral Visual Impairment now used (especially in Europe)


• Cerebral visual impairment: inclusive term• Reduced visual acuity • Oculomotor anomalies• Visual field loss• Vision information processing problems • Cognitive Visual Dysfunction (CVD)

•Used to identify visual perceptual anomalies

•Used to identify vision information processing problems


• Classification of CVI• Ocular visual impairment: Refractive state. Optics, Eye

health• Cerebral visual impairment: Neuro-pathway problems,

cortical problems, oculomotor dysfunction, vision information processing (dorsal and ventral streaming processing mechanisms)


The ventral stream (also known as the "what pathway") travels to the temporal lobe and is involved with object identification. The dorsal stream (or, "where pathway") terminates in the parietal lobe and process spatial locations.


• Delayed Visual Maturation (DVM)• DVM type I Visually impaired infants: improved

visual abilities by the age of 6 months, often without treatment.

• DVM type II: attention problems, associated with neurological/learning abnormalities. Improvement takes longer

• DVM III: children have nystagmus, albinism. Vision improves later, can improve to low-normal levels.

• DVM IV: associated with retinal, optic nerve, macular anomalies


• Defining Other Disorders and PCVI • Variability with defining disorders not uncommon• Autism rare anomaly

• Definition altered so that the number of those on the Spectrum is now considered epidemic

•Legal, legislative, health care, insurance issues


• Should we be concerned about how PVCI is defined?

Absolutely!

•American Association on Intellectual and Developmental Disabilities changed definition of mental retardation

•Decreasing IQ cut off point from to 80 to 70

•Added adaptive behavior qualifications

•Result: instantly cured hundreds of thousands of those with mental retardation/intellectual disability overnight


What we call a thing is very important

To name it is to have power over it

PCVI: References

• Dutton GN, Bax M. (eds). Visual impairment in children due to damage to the brain. Clinics in Developmental Medicine. no 186. MacKieth Press. London;2010.

• Strategies for dealing with visual problems due to cerebral visual impairment: Gillian McDaid, Debbie Cockburn, Gordon N Dutton available from http://www.ssc.education.ed.ac.uk/courses/vi&multi/vjan08i.html

• Alesterlund L, Maino D. That the blind may see: A review: Blindsight and its implications for optometrists. J Optom Vis Dev 1999;30(2):86-93

• Kran B. Mayer L. Vision impairment and brain damage. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:135-146.

PCVI: References

• Colenbrander A. What’s in a name? Appropriate terminology for CVI. J Vis Impair Blind. 2010:583-585

• Roman Lantzy CA, Lantzy A. Outcomes and opportunities: A study of children with cortical visual impairment. J Vis Impair Blind. 2010:649-653.

• http://www.aph.org/cvi/define.html

• Cerebral Visual Impairment in Periventricular Leukomalacia: MR Correlation: Available from http://www.ajnr.org/content/17/5/979.full.pdf


Determining Vision Function and

Functional Vision in Children with



Determining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment

•Need to assess vision function and functional vision •Vision function

•Clarity of vision (visual acuity, contrast sensitivity, refractive error, Amblyopia)



•Oculomotor ability (pursuits and saccades; convergence and divergence, strabismus)

•Pursuits/Visual Tracking

•Saccades



• Binocular Vision

• Convergence insufficiency/excess

• Divergence insufficiency/excess

• Strabismus

• Exotropia

• Esotropia

• Hypertropia



•Accommodation (focusing)

•Accommodative insufficiency

•Accommodative excess

• Ill-sustained accommodation

•Accommodative instability



• Depth perception (3D vision)

• Binocular vision (Stereoscopy) is the ability to align and focus both eyes accurately on an object and then combine the visual images from each eye into a single, clear, three dimensional perception. Difficulty seeing in 3D can arise when eye fatigue occurs, forcing the eyes to make adjustments to focus simultaneously on images that are near and far away.

• Symptoms indicating a potential problem viewing images in 3D can vary, but some common symptoms include headaches, blurred vision, nausea and dizziness.



• Eye health• Cornea, lens, pupil, • iris, vitreous, optic nerve, • retina

• Visual Cortex

• Other areas of the brain (motor,

• executive function)



• Special diagnostic tools• EOG (electrooculogram)• ERG (electroretinogram)• VER/VEP (visually evoked response visual evoked potential)


Vision Function of Children with Disability

Down Syndrome: Visual Acuity, Refractive Error, Strabismus/Oculomotor, Accommodation, Ocular health, Vision Information Processing, Other

Cerebral Palsy: Visual Acuity, Refractive Error, Strabismus/Oculomotor, Accommodation, Ocular Health, Vision Information Processing, Other

Brain Injury: Visual Acuity, Refractive Error, Strabismus/Oculomotor, Accommodation, Ocular Health, Vision Information Processing, Other


Functional vision

Functionally induced disability that

overlays pathologically induced disability• Uncorrected refractive error

• Amblyopia

• On top of vision loss due

• to cerebral impairment

• Down Syndrome

• Cerebral Palsy


• Vision information processing (VIP)/Visual perceptual skills

•Laterality/Directionality•Visual motor integration•Non-motor perceptual skills•Auditory perceptual/processing

References

• Luek AH. Cortical or cerebral visual impairment in children: A brief overview. J Vis Impair Blind. 2010:585-592.

• Woodhouse JM, Maino DM. Down syndrome: In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:31-40.

• Wesson M, Maino D. Oculo-visual findings in Down syndrome, cerebral palsy, and mental retardation with non-specific etiology. In Maino D (ed). Diagnosis and Management of Special Populations. Mosby-Yearbook, Inc. St. Louis, MO. 1995:17-54.

• Taub M, Reddell A. Cerebral Palsy. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:21-30.

References

• Ciuffreda K, Kapoor N. Acquired brain injury. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:95-100.

• Roman-Lantzy, C. Cortical visual impairment: An approach to assessment and intervention. AFB Press, NY, New York; 2007.

• http://www.3deyehealth.org/

• http://www.MainosMemos.blogspot.com


Therapeutic Strategies for the

Treatment of



• Treatment begins with the basics.

•Vision function

•Refractive correction

•Spectacles therapeutic

•Eye health


• Treatment with spectacle/lenses • multi-focal prescription/bifocal• prism• occlusion


• Treatment with spectacle/lenses • task specific glasses• high “+” adds (magnification)• Telescopes• Microscopes


•Vision Therapy•Oculomotor/hand-eye/accommodation

& fusion•Biocular•Binocular


• Vision Therapy• Integration/Stabilization•Visual stimulation•Vision information processing

•Vestibular/VisionApps 4 Vision Developmenthttp://www.sovoto.com/group/apps4VisionDevelopment


• Resources • Facebook

(http://www.facebook.com/Thinkingoutsidethelightbox)

• Pinterest http://pinterest.com/achampine0302/cortical-visual-impairment-cvi-goodies/

• Blogs http://www.MainosMemos.blogspot.com


Thinking Outside the LightBox


How Do Environmental Factors, Medications and Non-Visual Handicaps Affect the

Evaluation and Treatment of Pediatric Cerebral Visual Impairment?


For individuals with disability…

• Medications: Prescribed many more medications

• Higher affinity for adverse effects due to environmental/systemic factors

• Seldom complain of symptoms related to their disability, systemic anomalies, or medication side effects


•Alternative and complementary medical therapies

Maino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13-17

Lemer P. Complementary and Alternative Approaches. In Taub M, Bartuccio M, Maino D. Visual Diagnosis and Care of Patients with Special Needs. Lippincott, Williams, Wilkins. 2012

•Traditional allopathic approaches


•Mental illnesses in children•Pediatric Bipolar disorder•Pediatric depression


• Major environmental hazard: People•do not know how to respond

•make assumptions

•true for lay individuals, teacher, health care professionals

• Other

Medication Side Effects

Antidepressants Abdominal pain/constipation Blurred visionAbnormal dreams/thinking Increased risk of GlaucomaAbnormal ejaculation/orgasm Visual DisturbancesAnxiety Photophobia


Anticonvulsants

Memory problems/amnesia Blurred visionSedation Dimming of visionInsomnia DiplopiaBronchitis Involuntary eye movementsFluid retention Dry eye


Anti-Parkisons

Abnormal dreams/insomnia Vision abnormalitiesIncreased muscle tone/weakness Blurred visionInvoluntary movements MydriasisHallucinations Decreased accommodation


Tranquilizers

Breast development in men Risk of narrow angle GLCBreathing problems Cycloplegia/MydriasisInsomnia Decreased visionTardive dyskinesia Capsular cataract


Anti-anxiety

Anemia Decreased accommodationSeizures NystagmusBlood disorders DiplopiaUnusual excitement Mydriasis

Dominick M. Maino, O.D., M.Ed., F.A.A.O.

Professor, Pediatrics/Binocular Vision Service

Illinois College of OptometryIllinois Eye Institute

3241 S. Michigan Ave. Chicago, Il. 60616312-949-7280 (Voice) 312-949-7358 (fax)

[email protected] www.ico.edu

LyonsFamilyEyeCare.com MainosMemos.blogspot.com

Health & Medicine

97-2003 ppt american conference on pediatric cerebral visual impairment