Lecture Handouts: Pediatric Cortical Visual Impairment

5/23/2014

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Diagnosis and Therapeutic Intervention of Vision Function and Functional Vision Anomalies in PCV

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois College of Optometry

Lyons Family Eye CareChicago, Il

[email protected]

LyonsFamilyEyeCare.comMainosMemos.com

Vision Function and Functional Vision Anomalies in PCV

The American Conference on Pediatric Cortical Visual Impairment brings together professionals in optometry, ophthalmology, occupational therapy and visual educational psychology to increase the understanding of the definition, diagnosis and management of cortical vision loss in children.

(Dr Dominick Maino, PCVI Society Founding Board member, Dr. Joseph Maino, Dr. Kerri Pillen)


1. History and Definition of pediatric cortical visual impairment (PCVI).2. Describe the diagnostic criteria utilized in optometry.3. Discuss the treatment techniques.

Pediatric 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.

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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 (Blindsight).

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


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

Cerebral vs Cortical Visual Impairment

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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 lobeand process spatial locations.

Pediatric Cortical Visual Impairment

Reduced visual acuity due to a

“brain problem”


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

http://en.wikipedia.org/wiki/Two-streams_hypothesis#Ventral_stream

http://en.wikipedia.org/wiki/Temporal_lobe

http://en.wikipedia.org/wiki/Two-streams_hypothesis#Dorsal_stream

http://en.wikipedia.org/wiki/Parietal_lobe

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What we call a thing is very important

To name it is to have power over it


Determining Vision Function and

Functional Vision in Children with



Diagnostic Approaches & Strategies

1.Case History2.Visual Acuity3.Refractive Error4.Vision Function Assessment5.Ocular Health6.Special Tools


Vision Function

Clarity of vision (visual acuity, contrast sensitivity, refractive error)Oculomotor ability (pursuits and saccades; convergence and divergence)Accommodation (focusing)Depth perception (3D vision)


Vision FunctionEye health

BiomicroscopyTonometryDilated Fundus Evaluation

Special diagnostic toolsEOG (electrooculogram)ERG (electroretinogram)VER/VEP (visually evoked response visual evoked potential)


Functional Vision

Functionally induced disability that overlays pathologically induced disability

Uncorrected refractive error : AmblyopiaConstant Strabismus: Amblyopia Oculomotor dysfunction, Binocular vision dysfunction, Accommodative dysfunction: Attention

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Functional vision

Vision information processing (VIP)/ Visual perceptual skills

laterality/directionalityvisual motor integrationnon-motor perceptual skillsauditory perceptual/processing


Vision Function

Clarity of vision

What is visual acuity? What is contrast sensitivity?What is refractive error?


Vision Function

Clarity of vision

What is visual acuity?

The ability to see a certain size object at a certain distance.


Vision Function

Clarity of vision

What is contrast sensitivity?


Contrast sensitivity measures the ability to see details at low contrast levels. Visual information at low contrast levels is particularly important:

1. in communication, since the faint shadows on our faces carry the visual information related to facial expressions.


2. in orientation and mobility, where we need to see such critical low-contrast forms as the curb, faint shadows, and stairs when walking down. In traffic, the demanding situations are at low contrast levels, for example, seeing in dusk, rain, fog, snow fall, and at night.

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3. in every day tasks, where there are numerous visual tasks at low contrast, like cutting an onion on a light colored surface, pouring coffee into a dark mug, checking the quality of ironing, etc.


4. in near vision tasks like reading and writing, if the information is at low contrast as in poor quality copies or in a fancy, barely readable invitation, etc.

from http://www.lea-test.fi/en/vistests/pediatric/cstests/cstests.html

Vision Function and Functional Vision Anomalies in PCV Vision Function and Functional Vision Anomalies in PCV

Vision Function and Functional Vision Anomalies in PCV Vision Function and Functional Vision Anomalies in PCV

http://www.lea-test.fi/en/vistests/pediatric/cstests/cstests.html

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Tests of Visual Acuity and ContrastUsed with permission


Pursuits, Saccades, Convergence


Retinoscopy

Book (Getman) 1. At the Free and Easy reading level, the reflex varied from neutral to with motion and was bright, had sharp edges and had a pinkish color. 2. At the instructional reading level (which was defined as maintaining the reading task with comprehension in spite of being stressed) the reflex was a varying fast against motion while the color was bright, sharp, and very pink. 3. At the frustration reading level (which was defined as reading with minimal comprehension) the reflex showed a slow against motion with a dull brick red color.

Bell (Apell) Dynamic (#5 & #6 OEP) MEM (Haynes)


Retinoscopy

Bell (Apell)

Target(Wolf Wand) directly in front of the retinoscopePatient fixates the target Move the ball toward the patient slowly and smoothlyThe distance of the target from the patient is recorded for a change in motion or other changes of interest Expect to see a change from “with” to “against” on the way in at 35 - 42 cm. (14 - 17inches) and a change from “against” to with at 37.5 - 45 cm. (15 -18 inches).

Dynamic (#5 & #6 OEP) MEM (Haynes)


Retinoscopy

Dynamic (#5 & #6 OEP)Distance retinoscopy (#4) in placePatient behind the phoropterExaminer’s retinoscope at a 20 (twenty) inch distance from the patient. Patient fixates small letters or a picturePatient looks, reads, names, and interact visually with the target Plus spheres added until against motion is seenThen plus spheres are reduced until the first neutral (no motion) response Lens in the phoropter is recorded as the “gross” finding. The #5 retinoscopy, like the other “21 point findings”, had no specific meaning by itself until it was compared to other findings as part of the total analytical examination. The #5, like the 14B gross, will approximate the most plus lens acceptable for near.

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Retinoscopy

MEM Retinoscopy (Monocular Estimation Method)

Patient reads grade appropriate material usually affixed to the retinoscopeWorking distance is the patient’s Harmon distanceQuickly “dip” lenses in front of the reading materialA +.25 to +.75 lag of accommodation is considered normalA high lag would be +1.00 or greaterAccommodative excess would be any AM notedAlso note variability of reflex, color and other variability

Stress Point RetinoscopyKraskin & Harmon

For more info see: http://www.oepf.org/VTAids/Retinoscopy.pdf

Retinoscopy

Color vision, copy forms, Matching, Visual Fields


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

http://www.oepf.org/VTAids/Retinoscopy.pdf

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Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment


Treatment with spectacle/lenses/computer devices

task specific glasses

high “+” adds (magnification)

Telescopes

Microscopes


Vision Therapy

Oculomotor/hand-eye/accommodation

& fusion

Biocular

Binocular

Integration


Vision Therapy Integration/Stabilization

Visual stimulation

Vision information processing

Vestibular/Vision

Apps 4 Vision Development

http://www.sovoto.com/group/apps4VisionDevelopment


Perceptual Learning vs Vision Therapy

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Thinking Outside the LightBox


Think Outcomes!


What follows is supplemental information

to the presentation, resources and

references that are not necessarily a part of

this presentation, but which I thought you

would like to have for your own

information.


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

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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

Medication Side Effects

Antidepressants

Abdominal pain/constipation Blurred vision

Abnormal dreams/thinking Increased risk of

Disturbances

Anxiety Photophobia


Anticonvulsants

Memory problems/amnesia Blurred vision

Sedation Dimming of vision

Insomnia Diplopia

Bronchitis Involuntary eye movements

Fluid retention Dry eye


Anti-Parkisons

Abnormal dreams/insomnia Vision abnormalities

Increased muscle tone/weakness Blurred vision

Involuntary movements Mydriasis

Hallucinations Decreased

accommodation


Tranquilizers

Breast development in men Risk of narrow angle GLC

Breathing problems Cycloplegia/Mydriasis

Insomnia Decreased vision

Tardive dyskinesia Capsular cataract

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Anti-anxiety

Anemia Decreased accommodation

Seizures Nystagmus

Blood disorders Diplopia

Unusual excitement Mydriasis

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

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, BartuccioM, 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.MainosMemos.com

Pediatric Cerebral Visual Impairment Resources

Facebook (http://www.facebook.com/Thinkingoutsidethelightbox) Pinterest http://pinterest.com/achampine0302/cortical-visual-

impairment-cvi-goodies/ Blogs http://www.MainosMemos.blogspot.com Apps http://www.sovoto.com/group/apps4VisionDevelopment Infant Visual Stimulations https://itunes.apple.com/us/app/infant-

visual-stimulation/id427443223 Infant Visual Stimulation Video

https://www.youtube.com/watch?v=Eyj5PqwUn0w COVD http://www.COVD.org OEPF http://www.OEPF.org Vision Help blog http://visionhelp.wordpress.com/ MainosMemos http://www.MainosMemos.blogspot.com

http://www.ssc.education.ed.ac.uk/courses/vi&multi/vjan08i.html

http://www.aph.org/cvi/define.html

http://www.ajnr.org/content/17/5/979.full.pdf

http://www.mainosmemos.com/

http://www.facebook.com/Thinkingoutsidethelightbox

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

http://www.mainosmemos.blogspot.com/

http://www.sovoto.com/group/apps4VisionDevelopment

https://itunes.apple.com/us/app/infant-visual-stimulation/id427443223

https://www.youtube.com/watch?v=Eyj5PqwUn0w

http://www.covd.org/

http://www.oepf.org/

http://visionhelp.wordpress.com/

http://www.mainosmemos.blogspot.com/

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Dominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular Vision Illinois Eye Institute

Illinois College of Optometry3241 S. Michigan Ave. Chicago, Il 60616

Lyons Family Eye Care3250 N. Lincoln Ave. Chicago, Il 60657

[email protected]

LyonsFamilyEyeCare.comMainosMemos.com

Health & Medicine

Lecture Handouts: Pediatric Cortical Visual Impairment