Diagnosis and TherapeuticIntervention of Vision Function andFunctional Vision Anomalies in PCV
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A      Professor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois Col...
Presenter DisclosuresConsultant/           Expert Witness/Legal Consultant-Gilbert & Tobin, Sydney, Australia             ...
Vision Function and Functional Vision Anomalies in PCVThe American Conference on Pediatric Cortical Visual Impairmentbring...
Vision Function and Functional Vision Anomalies in PCV1. Define pediatric cortical visual impairment (PCVI).2. Describe th...
Vision Function and Functional Vision Anomalies in PCV4. Demonstrate problem-solving strategies when evaluating the newPCV...
Vision Function and Functional Vision Anomalies in PCV7. Identify the causes of PCVI.8. Discuss research topics which furt...
Vision Function and Functional Vision Anomalies in PCV                                              An                    ...
Vision Function and Functional Vision Anomalies in PCV              Pediatric Cerebral Visual Impairment (PCVI)           ...
Diagnosis and Therapeutic Intervention of Vision Function and             Functional Vision Anomalies in PCV Describe the ...
Vision Function and Functional Vision Anomalies in PCV         Diagnostic Approaches & Strategies       1.Case History    ...
Vision Function and Functional Vision Anomalies in PCV                    Vision Function       Clarity of vision (visual ...
Vision Function and Functional Vision Anomalies in PCV               Vision Function:Eye health       Biomicroscopy, Tonom...
Vision Function and Functional Vision Anomalies in PCV                    Functional VisionFunctionally induced disability...
Vision Function and Functional Vision Anomalies in PCV                     Functional visionVision information processing ...
Vision Function and Functional Vision Anomalies in PCVHistory       All the usual questions AND       General/Motor/Visual...
Vision Function and Functional Vision Anomalies in PCV                    Vision Function       Clarity of vision         ...
Vision Function and Functional Vision Anomalies in PCV        Vision Function: Clarity of vision             What is visua...
Vision Function and Functional Vision Anomalies in PCV Tests of Visual Acuity
Vision Function and Functional Vision Anomalies in PCV                   Vision Function:                     Clarity of v...
Vision Function and Functional Vision Anomalies in PCV              Contrast sensitivity measures the ability to          ...
Vision Function and Functional Vision Anomalies in PCV              2. in orientation and mobility, where              we ...
Vision Function and Functional Vision Anomalies in PCV              3. in every day tasks, where there              are nu...
Vision Function and Functional Vision Anomalies in PCV           4. in near vision tasks like reading           and writin...
Vision Function and Functional Vision Anomalies in PCV         Regular                           Low         Contrast     ...
Vision Function and Functional Vision Anomalies in PCV         Regular Contrast           Low Contrast
Vision Function and Functional Vision Anomalies in PCV
Vision Function and Functional Vision Anomalies in PCV
Vision Function and Functional Vision Anomalies in PCV                 Refractive Error   Myopia (Nearsightedness)   Hyper...
Vision Function and Functional Vision Anomalies in PCV            Refractive Error        Myopia (Nearsightedness)
Vision Function and Functional Vision Anomalies in PCVRefractive Error: Myopia (Nearsightedness)
Vision Function and Functional Vision Anomalies in PCVRefractive Error: Hyperopia (Farsightedness)
Vision Function and Functional Vision Anomalies in PCV  Refractive Error: Astigmatism
Vision Function and Functional Vision Anomalies in PCV  Refractive Error: Astigmatism
Vision Function and Functional Vision Anomalies in PCV  Refractive Error: Assessment  Objective   Dry Retinoscopy   Cyclop...
Vision Function and Functional Vision Anomalies in PCVRefractive Error: AssessmentObjective  Dry Retinoscopy  Mohindra Dyn...
Vision Function and Functional Vision Anomalies in PCV  Refractive Error: Assessment  Objective    Mohindra Dynamic Retino...
Objective: Auto-refractionPediavision SPOT: See Maino D, Goodfellow G. Tomorrow’sPractice Today: SPOT On! AOANews 2013; Ma...
Vision Function and Functional Vision Anomalies in PCVRefractive Error:Assessment       SubjectiveWhich is better 1 or 2?
Oculomotor ability basic extra-ocular muscle assessmentPursuitsSaccadesConvergenceDivergence
Oculomotor abilitybasic extra-ocular muscle assessment
Oculomotor abilityConvergence   Divergence
Accommodation   (focusing)  MEM Nott  Book Bell
Accommodation (focusing)Monocular Estimate Method (MEM): you neutralize thereflex while the patient accommodates to a targ...
Accommodation (focusing)MEM     Room illumination should be dim but with     target illuminated     Briefly insert lens in...
Accommodation (focusing)Nott Method: clinician moves toward andaway from the patient until neutrality isseen (Dioptric dif...
Accommodation (focusing)          Book RetinoscopyTechnique developed at the Gesell Instituteby Gerry Getman, OD working w...
Accommodation (focusing)                     Book1. Free and Easy reading level, reflex variedfrom neutral to with motion ...
Accommodation (focusing)                  Book3. Frustration reading level (reading withminimal comprehension) the reflex ...
Accommodation (focusing)                  Bell RetinoscopyA small shiny bell dangling from a string is usedas a fixation t...
BinocularityFusionStereopsisDepth Perception(3D vision)
BinocularityFusionStereopsisDepth Perception(3D vision)
BinocularityFusionStereopsisDepth Perception(3D vision)
Binocularity   Cover Test
Testing Your Binocularity   Finger Test  Brock String     Circles
Color Vision
Eye Health  Biomicroscopy  Dilated Fundus    Evaluation   Visual Fields
Eye Health
Special diagnostic tools EOG (electrooculogram) ERG (electroretinogram) VER/VEP (visually evoked response visual evoked po...
Special diagnostic tools ERG VER/VEP TOVA Visagraph
Functional Vision Anomalies in PCVAmblyopia, Strabismus, Oculomotility Disorder, AccommodativeDisorders, Binocular Vision ...
Treatment of Functional Vision Anomalies in PCVTreatment begins with the basicsVision functionRefractive error & quality o...
Treatment of Functional Vision Anomalies in PCV        Treatment with spectacles      multi-focal prescription/bifocal    ...
Treatment of Functional Vision Anomalies in PCV         Treatment with spectacles  “The medicine in my  glasses has run ou...
Treatment of Functional Vision Anomalies in PCV     Vision Therapy/Vision Rehabilitation/              Vision Stimulation ...
Treatment of Functional Vision Anomalies in PCVVision Therapy/Vision Rehabilitation/         Vision Stimulation           ...
Treatment of Functional Vision Anomalies in PCV     Vision Therapy/Vision Rehabilitation/              Vision Stimulation ...
Treatment of Functional Vision Anomalies in PCV            Suggestions from members
Treatment of Functional Vision Anomalies in PCVHow To Modify your Home for Visual StimulationRationale-Environment- direct...
Treatment of Functional Vision Anomalies in PCVIncrease contrast-       Use electrical colored tape, stickers, decals to a...
Treatment of Functional Vision Anomalies in PCVSuggested Materials and Activities to try-Mobiles- suspend colorful Mylar, ...
Treatment of Functional Vision Anomalies in PCVShow, Tell & Reach-Develops understanding of objects and immediateworld thr...
Treatment of Functional Vision Anomalies in PCVShow, Tell & Reach-How to do-Slow down the pace during activitiesRoutinely ...
Treatment of Functional Vision Anomalies in PCVDefined Spaces or Play spaces- Provides incentive for movement, exploration...
Treatment of Functional Vision Anomalies in PCVDefined Spaces or Play spaces-Keep objects predictable and highly meaningfu...
Treatment of Functional Vision Anomalies in PCVDefined Spaces or Play spaces-Sittin’ Center- adapted seating with toys sec...
Treatment of Functional Vision Anomalies in PCV I love … the use of shiny emergency blankets. They are likelarge sheets of...
Treatment of Functional Vision Anomalies in PCV
Medications and Alternative TherapiesMedications: Prescribed many moremedicationsHigher affinity for adverse effects due t...
Medications and Alternative TherapiesAlternative and complementarymedical therapiesTraditional allopathic approachesMental...
Medications and Alternative TherapiesMajor environmental hazard:People do not know how torespond, make assumptionstrue for...
Other Topics4. Demonstrate problem-solving strategieswhen evaluating the new PCVI patient5. Develop a multidisciplinary ap...
Case ReviewsCase Guided Workshop: The role of the Optometrist in theManagement of the PCVI PatientAcknowledgements:Dr. Tra...
Case Reviews                     Case #1Hx: 2 year 4 mo old, ischemic changes in the cortexwith both white and deep grey m...
Case Reviews                     Case #1Medications: Multiple medicationsParticipates in vision therapy, developmental tx,...
Case Reviews                    Case #1VF using toys/OKN drum. Responded well inall visual fields.Contrast sensitivity at ...
Case Reviews                      Case #1OD +2.50-2.00X005 OS +2.50-2.50X177Old Rx Mohindra Ret +3.75-2.50X180 OD+3.50-2,5...
Case Reviews                Case #1RecommendationsHigh degree of vision function.Continue to work withdevelopmental therap...
Case Reviews                    Case #2Hx: 2 y 5 mo female, picks up toys more,increased facial expressions, still using g...
Case Reviews                     Case #2phenobarbital, ROS unremarkable except forwhat is noted above. Strong tracking all...
Case Reviews                     Case #311 yr 6 m F. vision problems noted at 8mos ofage, optic nerve hypoplasia, nystagmu...
Case Reviews                    Case #3OD +.75-3.00X170 OS +1.00-4.00X010 cycloOKN/Teller UTT, can separate head from eyem...
Case Reviews                    Case #42 y/o HM, genetic mutation L1CAM that leadto hydrocephalus and developmental delays...
Case Reviews                Case #4Teller 20/180, Cardif 20/80, +tracking,+OKN, + eyehand, FROM, Ta 26, 26 lidsheld, +2.25...
8. Discuss research topics whichfurther the knowledge base ofPCVI.Little research on pure PCVI
Rehabilitation of cortical visual impairment in children. Denise E Malkowicz,Ginette Myers, Gerry Leisman in The Internati...
Optom Vis Sci. 2005 Sep;82(9):807-16. Retrospective analysis of refractive errorsin children with vision impairment. Du JW...
9. The use of social media andthe internet to disseminateinformation about PCVI.Websites for information
Cortical Visual Impairment Pediatric Visual Diagnosis FactSheet http://www.aph.org/cvi/articles/bbf_1.htmlCortical Visual ...
Social Media                    Pinteresthttp://pinterest.com/pediastaff/visual-impairment/                    FacebookPre...
Social Media                    Blogs http://adayinourshoes.com/tag/cortical-visual-                 impairment/
Resources:Dutton GN, Bax M (eds). Visual Impairment in Children due to Damage to theBrain. Clinics in Developmental Medcin...
ResourcesInternethttp://drleahyvarinen.com/http://Mainosmemos.comhttp://www.slideshare.net/DMAINO/https://www.facebook.com...
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A      Professor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois Col...
2nd Annual Conference on Pediatric Cortical Visual Impairment
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2nd Annual Conference on Pediatric Cortical Visual Impairment

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2nd Annual Conference on Pediatric Cortical Visual Impairment feature four keynote speakers. I was fortunate to be one of them. This is the PowerPoint of my presentation.

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Transcript of "2nd Annual Conference on Pediatric Cortical Visual Impairment"

  1. 1. Diagnosis and TherapeuticIntervention of Vision Function andFunctional Vision Anomalies in PCV
  2. 2. Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois College of Optometry Lyons Family Eye Care Chicago, Il dmaino@ico.edu ICO.edu LyonsFamilyEyeCare.com MainosMemos.com
  3. 3. Presenter DisclosuresConsultant/ Expert Witness/Legal Consultant-Gilbert & Tobin, Sydney, Australia American Optometric Association Spokes Person, LecturerSpeakers bureaus American Academy of Optometry, Lecturer College of Optometrists in Vision Development, Lecturer Pacific University College of Optometry, LecturerResearch funding “No Disclosures.”Stock “No Disclosures.”ownership/Corporateboards-employmentOff-label uses “No Disclosures.”Editor/Author Visual Diagnosis and Care of the Patient with Special Needs, Lippincott, 2012; American Optometric Association News
  4. 4. Vision Function and Functional Vision Anomalies in PCVThe American Conference on Pediatric Cortical Visual Impairmentbrings together professionals inoptometry, ophthalmology, occupational therapy and visualeducational psychology to increase the understanding of thedefinition, diagnosis and management of cortical vision loss inchildren.
  5. 5. Vision Function and Functional Vision Anomalies in PCV1. Define pediatric cortical visual impairment (PCVI).2. Describe the diagnostic criteria utilized in occupational therapy,teachers of the visually impaired, optometry and ophthalmology.3. Discuss the management and treatment techniques utilized inoccupational therapy, teachers of the visually impaired, optometryand ophthalmology.
  6. 6. Vision Function and Functional Vision Anomalies in PCV4. Demonstrate problem-solving strategies when evaluating the newPCVI patient.5. Develop a multidisciplinary approach to the newly diagnosedPCVI patient.6. Network with professionals in related medical and educationaldisciplines who can serve as resources for improved vision care forPCVI patients.
  7. 7. Vision Function and Functional Vision Anomalies in PCV7. Identify the causes of PCVI.8. Discuss research topics which further the knowledge base of PCVI.9. The use of social media and the internet to disseminateinformation about PCVI.
  8. 8. Vision Function and Functional Vision Anomalies in PCV An Introduction1. Define pediatric cortical visual impairment (PCVI)Definition confusing, misunderstood and imprecise. Pediatric Cerebral Visual Impairment (PCVI). Pediatric Cortical Visual Impairment Delayed Visual Development
  9. 9. Vision Function and Functional Vision Anomalies in PCV Pediatric Cerebral Visual Impairment (PCVI) Pediatric Cortical Visual ImpairmentNorth America: Cortical Visual ImpairmentElsewhere: Cerebral Visual Impairment Cerebral visual impairment: inclusive term Ocular visual impairment: Refractive state, Optics, Eye health Cerebral visual impairment: Neuro-pathway problems,cortical problems, oculomotor dysfunction, vision informationprocessing (dorsal and ventral streaming processing mechanisms)For more in depth information please see: Maino D. Pediatric Cerebral Visual Impairment. Optom Vis Dev 2012:43(3):115-120 (availablefrom http://www.slideshare.net/DMAINO/maino-cortical-visual-impairment)
  10. 10. Diagnosis and Therapeutic Intervention of Vision Function and Functional Vision Anomalies in PCV Describe the diagnostic criteria utilized in …… optometry and ophthalmology.
  11. 11. Vision Function and Functional Vision Anomalies in PCV Diagnostic Approaches & Strategies 1.Case History 2.Visual Acuity 3.Refractive Error 4.Vision Function Assessment 5.Ocular Health 6.Special Tools
  12. 12. Vision Function and Functional Vision Anomalies in PCV 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)
  13. 13. Vision Function and Functional Vision Anomalies in PCV Vision Function:Eye health Biomicroscopy, Tonometry Dilated Fundus Evaluation Special diagnostic tools EOG (electrooculogram) ERG (electroretinogram) VER/VEP (visually evoked response visual evoked potential)
  14. 14. Vision Function and Functional Vision Anomalies in PCV Functional VisionFunctionally induced disability that overlayspathologically induced disability Uncorrected refractive error : Amblyopia Constant Strabismus: Amblyopia Oculomotor dysfunction, Binocular vision dysfunction, Accommodative dysfunction: Attention
  15. 15. Vision Function and Functional Vision Anomalies in PCV Functional visionVision information processing (VIP)/Visual perceptual skills laterality/directionality visual motor integration non-motor perceptual skills auditory perceptual/processing
  16. 16. Vision Function and Functional Vision Anomalies in PCVHistory All the usual questions AND General/Motor/Visual/Auditory Development Daily Living Skills Skills needed for Learning
  17. 17. Vision Function and Functional Vision Anomalies in PCV Vision Function Clarity of vision What is visual acuity? What is contrast sensitivity? What is refractive error?
  18. 18. Vision Function and Functional Vision Anomalies in PCV Vision Function: Clarity of vision What is visual acuity? The ability to see a certain size object at a certain distance . .
  19. 19. Vision Function and Functional Vision Anomalies in PCV Tests of Visual Acuity
  20. 20. Vision Function and Functional Vision Anomalies in PCV Vision Function: Clarity of vision What is contrast sensitivity?
  21. 21. Vision Function and Functional Vision Anomalies in PCV 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.
  22. 22. Vision Function and Functional Vision Anomalies in PCV 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.
  23. 23. Vision Function and Functional Vision Anomalies in PCV 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.
  24. 24. Vision Function and Functional Vision Anomalies in PCV 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/instruct/contrast/csensiti/csensiti.html
  25. 25. Vision Function and Functional Vision Anomalies in PCV Regular Low Contrast Contrast
  26. 26. Vision Function and Functional Vision Anomalies in PCV Regular Contrast Low Contrast
  27. 27. Vision Function and Functional Vision Anomalies in PCV
  28. 28. Vision Function and Functional Vision Anomalies in PCV
  29. 29. Vision Function and Functional Vision Anomalies in PCV Refractive Error Myopia (Nearsightedness) Hyperopia (Farsightedness) Astigmatism
  30. 30. Vision Function and Functional Vision Anomalies in PCV Refractive Error Myopia (Nearsightedness)
  31. 31. Vision Function and Functional Vision Anomalies in PCVRefractive Error: Myopia (Nearsightedness)
  32. 32. Vision Function and Functional Vision Anomalies in PCVRefractive Error: Hyperopia (Farsightedness)
  33. 33. Vision Function and Functional Vision Anomalies in PCV Refractive Error: Astigmatism
  34. 34. Vision Function and Functional Vision Anomalies in PCV Refractive Error: Astigmatism
  35. 35. Vision Function and Functional Vision Anomalies in PCV Refractive Error: Assessment Objective Dry Retinoscopy Cycloplegic Retinoscopy Mohindra Dynamic Retinoscopy Auto-refraction
  36. 36. Vision Function and Functional Vision Anomalies in PCVRefractive Error: AssessmentObjective Dry Retinoscopy Mohindra Dynamic Retinoscopy Cycloplegic Retinoscopy
  37. 37. Vision Function and Functional Vision Anomalies in PCV Refractive Error: Assessment Objective Mohindra Dynamic Retinoscopy Dark room 50 cm Neutralize main meridians Algebraically add -1.25 to sph
  38. 38. Objective: Auto-refractionPediavision SPOT: See Maino D, Goodfellow G. Tomorrow’sPractice Today: SPOT On! AOANews 2013; March:29URL http://www.spotvisionscreening.com/2013/
  39. 39. Vision Function and Functional Vision Anomalies in PCVRefractive Error:Assessment SubjectiveWhich is better 1 or 2?
  40. 40. Oculomotor ability basic extra-ocular muscle assessmentPursuitsSaccadesConvergenceDivergence
  41. 41. Oculomotor abilitybasic extra-ocular muscle assessment
  42. 42. Oculomotor abilityConvergence Divergence
  43. 43. Accommodation (focusing) MEM Nott Book Bell
  44. 44. Accommodation (focusing)Monocular Estimate Method (MEM): you neutralize thereflex while the patient accommodates to a target atnear (usually at 40cm) With motion: Lag of accommodation --- Add PLUS Against motion: Lead of accommodation - Add MINUS Use patient’s correction for distance or near TRUE measurement of lag/lead if measured with BVA Place the target at their working distance Adults: usually 40 cm Children: use Harmon’s distance
  45. 45. Accommodation (focusing)MEM Room illumination should be dim but with target illuminated Briefly insert lens into line of sight Measurements should be made within 1 second per lens used to minimize the dazzle of light and the effect of lens on accommodation systemThe lens that creates neutrality is the value
  46. 46. Accommodation (focusing)Nott Method: clinician moves toward andaway from the patient until neutrality isseen (Dioptric difference between neutral and yourbeginning distance is the lead/lag) Against motion: move closer to the patient With motion: move further away from patient
  47. 47. Accommodation (focusing) Book RetinoscopyTechnique developed at the Gesell Instituteby Gerry Getman, OD working with ArnoldGesell, MD.
  48. 48. Accommodation (focusing) Book1. Free and Easy reading level, reflex variedfrom neutral to with motion withbright, sharp edges and had a pinkish color.2. Instructional reading level (maintainingthe reading task with comprehension in spiteof being stressed) the reflex was a varyingfast against motion while the color wasbright, sharp, and very pink.
  49. 49. Accommodation (focusing) Book3. Frustration reading level (reading withminimal comprehension) the reflex showed aslow against motion with a dull brick redcolor.
  50. 50. Accommodation (focusing) Bell RetinoscopyA small shiny bell dangling from a string is usedas a fixation target (now use a silver ball on thetop of a stick). The ball is moved closer to andfarther from the patient along this midline.The retinoscope is positioned slightly abovethis line at a fixed distance of 50 cm. (20inches) from the patient. Watch what happensto the reflex as you move the ball.
  51. 51. BinocularityFusionStereopsisDepth Perception(3D vision)
  52. 52. BinocularityFusionStereopsisDepth Perception(3D vision)
  53. 53. BinocularityFusionStereopsisDepth Perception(3D vision)
  54. 54. Binocularity Cover Test
  55. 55. Testing Your Binocularity Finger Test Brock String Circles
  56. 56. Color Vision
  57. 57. Eye Health Biomicroscopy Dilated Fundus Evaluation Visual Fields
  58. 58. Eye Health
  59. 59. Special diagnostic tools EOG (electrooculogram) ERG (electroretinogram) VER/VEP (visually evoked response visual evoked potential) TOVA (Test of Variables Attention) Visagraph/Computerized Assessment of Eye Movements
  60. 60. Special diagnostic tools ERG VER/VEP TOVA Visagraph
  61. 61. Functional Vision Anomalies in PCVAmblyopia, Strabismus, Oculomotility Disorder, AccommodativeDisorders, Binocular Vision DisordersDown Syndrome Review (see Woodhouse M. Maino D. DownSyndrome. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosisand Care of the Patient with Special Needs; Lippincott Williams &Wilkins. New York, NY;2012:31-40.)Cerebral Palsy Review (see Taub MB, Reddell AS. Cerebral Palsy. InTaub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care ofthe Patient with Special Needs; Lippincott Williams & Wilkins. NewYork, NY;2012:21-30.)
  62. 62. Treatment of Functional Vision Anomalies in PCVTreatment begins with the basicsVision functionRefractive error & quality of lifeSpectacles therapeuticEye health
  63. 63. Treatment of Functional Vision Anomalies in PCV Treatment with spectacles multi-focal prescription/bifocal prism occlusion task specific glasses high “+” adds (magnification) Low Vision Aids
  64. 64. Treatment of Functional Vision Anomalies in PCV Treatment with spectacles “The medicine in my glasses has run out!”
  65. 65. Treatment of Functional Vision Anomalies in PCV Vision Therapy/Vision Rehabilitation/ Vision Stimulation Use Principles of Neuroplasticity Use it or lose it Use it and improve it Specificity Repetition matters Intensity matters
  66. 66. Treatment of Functional Vision Anomalies in PCVVision Therapy/Vision Rehabilitation/ Vision Stimulation Maino D, Donati R, Pange Y, Viola S, Barry S. Neuroplasticity. In Taub M, Bartuccio M, Maino DM. (eds) Use Principles of Visual Diagnosis and Care of the Patient with Special Needs. Neuroplasticity Lippincott 2012. Time matters Kleim JA, Jones TA. Principles of experience-dependent neural Salience matters plascitity: implications for rehabilitation after brain damage. J Age matters Speech Lang Hear Res. 2008;51;S225- 39. Transference Interference
  67. 67. Treatment of Functional Vision Anomalies in PCV Vision Therapy/Vision Rehabilitation/ Vision Stimulation Use Principles of NeuroplasticityOculomotor/hand-eye, Biocular, BinocularIntegration/Stabilization, Visual stimulation,Vision informationprocessing, Vestibular/Vision Computerapplications
  68. 68. Treatment of Functional Vision Anomalies in PCV Suggestions from members
  69. 69. Treatment of Functional Vision Anomalies in PCVHow To Modify your Home for Visual StimulationRationale-Environment- directly impacts visual development andbrain cellsLighting- to increase stimulation of brain cellsOpen drapes- position child’s back to windows/doorsUse In-direct lighting – floor or desks lamps are best andreduce glare (direct light may damage retinal tissues);compact fluorescent bulbs -16 or 22 Watt with warm color
  70. 70. Treatment of Functional Vision Anomalies in PCVIncrease contrast- Use electrical colored tape, stickers, decals to add to objects(bottles, cups) walls, cribs Use plain colored sheets, poster board to hang on walls/corners to then attach objects, fabrics to make playspaces or rooms around the home more stimulating Use patterned fabrics, carpet squares, cellophane, clear plastic- to add to walls, windows, play spaces Make a “stained glass” window or mobile- use cellophanes, CD’s, mylar wrapping papers Use carpet squares on floor to mark areas; paint/tape on floor moldings or door jams
  71. 71. Treatment of Functional Vision Anomalies in PCVSuggested Materials and Activities to try-Mobiles- suspend colorful Mylar, CD’s, strings- provides movementand shiny objectsScreen savers- computer backgrounds are very stimulating and canbecome a cause and effect activityHousehold items- use soup cans, quacker oatscontainers, spoons, metal bowls, colorful cupsAdhesives- wall decals, stickers; add to lower places on walls**Be aware of what you wear or what other sounds are in the environment; competingstimuli make it harder to visually attend and focusBarbara Halton-Bailey, Education Coordinator Virginia Dept. f/t Blind
  72. 72. Treatment of Functional Vision Anomalies in PCVShow, Tell & Reach-Develops understanding of objects and immediateworld through hands on experienceHelps understand daily routinesDevelops better visual and/or motor responsesBuilds sound localizationIncreases active involvementLays the groundwork for crawling and walking
  73. 73. Treatment of Functional Vision Anomalies in PCVShow, Tell & Reach-How to do-Slow down the pace during activitiesRoutinely take 5 minutes or so; tell what object is and what ishappening, allow extra time for baby to “study” with hands, ears,eyes and bodyProvide assistance with reachingBabies may need to hold and “get to know” it by touching it beforeunderstanding and reaching for it away from the bodyGradually put familiar toys a few inches away (after initially touching)and make a sound for baby to reach for the objectBarbara Halton-Bailey, Education Coordinator Virginia Dept. f/t Blind
  74. 74. Treatment of Functional Vision Anomalies in PCVDefined Spaces or Play spaces- Provides incentive for movement, exploration, and independentinteractionA life-long organizational strategy to enhance efficiency ofmovement, independence and self-esteem-the use of defined spacesexpands and grows with the childUse walls and furniture as reference points in each room of thehouseFirst place toys touching body as baby plays on tummy, back, side orseated on the play space.Move objects further away and make sounds with the object forbaby to reach for
  75. 75. Treatment of Functional Vision Anomalies in PCVDefined Spaces or Play spaces-Keep objects predictable and highly meaningful to the child in eachareaBe sure objects are easily accessible with the child’s current abilitiesReturn child to the play space frequently showing where 2 or 3 toysare, throughout the day and allow the child to play independentlyExamples:Floor space- pallet with a border on 2-3 sides created bywalls, furniturePull-up space- arranged beside sofa, chairs, shelves, tablesCrib- use only if child enjoys waking periods in the crib
  76. 76. Treatment of Functional Vision Anomalies in PCVDefined Spaces or Play spaces-Sittin’ Center- adapted seating with toys secured within reachbeside, in front, and aboveEatin’ place- High chair, tray table-arrange cup and bowlKitchen space- special cabinet designated and marked, containingchild-safe pots. Lids containers, spoonsOuter space- area in backyard defined by playequipment, furniture, garden fencing, wind chimes. Have predictablestorage of outdoor toys, wheeled vehicles, push carts, radio or musicused as a sound source to return to the door.Barbara Halton-Bailey, TVI, NBCTEducation Coordinator, DBVI
  77. 77. Treatment of Functional Vision Anomalies in PCV I love … the use of shiny emergency blankets. They are likelarge sheets of reflective Mylar material that kids love towrap themselves in and look at the reflection of the lightoff of the wrinkles created in the sheets. ….reflectiveChristmas gift bags, water bottles filled with glitter, snapand light up neon bracelets or necklaces, pompoms, shinyreflective beaded necklaces, feather boas and the list goeson and on. Sometimes just using neon coloured duct tapeover a baby bottle or favorite toy works wonders.Jody Whelan, Specialist, Early Intervention Early Childhood VisionConsultant Northeast Blind Low Vision Early Intervention Program
  78. 78. Treatment of Functional Vision Anomalies in PCV
  79. 79. Medications and Alternative TherapiesMedications: Prescribed many moremedicationsHigher affinity for adverse effects due tosystemic/environmental factorsSeldom complain of symptoms relatedto their disability, systemic anomalies,or medication side effects
  80. 80. Medications and Alternative TherapiesAlternative and complementarymedical therapiesTraditional allopathic approachesMental illnesses in childrenPediatric Bipolar disorderPediatric depression
  81. 81. Medications and Alternative TherapiesMajor environmental hazard:People do not know how torespond, make assumptionstrue for layindividuals, teachers, health careprofessionals
  82. 82. Other Topics4. Demonstrate problem-solving strategieswhen evaluating the new PCVI patient5. Develop a multidisciplinary approach tothe newly diagnosed PCVI patient6. Network with professionals in relatedmedical and educational disciplines who canserve as resources for improved vision carefor PCVI patients
  83. 83. Case ReviewsCase Guided Workshop: The role of the Optometrist in theManagement of the PCVI PatientAcknowledgements:Dr. Tracy Matchinski: The Chicago Lighthouse for People who areBlind or Visually ImpairedDr. Mary Flynn-Roberts: Illinois Eye Institute/Illinois College ofOptometry Electrodiagnostic Service
  84. 84. Case Reviews Case #1Hx: 2 year 4 mo old, ischemic changes in the cortexwith both white and deep grey matter diffuseabnormalities, CP spastic quad, DD, seizures sincebirth (infantile spasms)Dx: CVI, Delayed visual maturation, exotropia.Placental umbilical cord problems, lower heart rate,meconium aspiration, profound hearing lossbilateral cochlear implants, encephalopathy
  85. 85. Case Reviews Case #1Medications: Multiple medicationsParticipates in vision therapy, developmental tx,speech/OT/PT, PT pool,VA 20/300 PL Teller Cards, 38 cm test dist. OUHorizontal tracking fine, vertical much moredifficultBinocularity inadequate most of the time, IAXT 30-35PD
  86. 86. Case Reviews Case #1VF using toys/OKN drum. Responded well inall visual fields.Contrast sensitivity at 10% level, moderatelyreduced for his ageRefraction hyperopia/astigmatism.Tolerates glasses well. No change from lastprescription.
  87. 87. Case Reviews Case #1OD +2.50-2.00X005 OS +2.50-2.50X177Old Rx Mohindra Ret +3.75-2.50X180 OD+3.50-2,50X180Near VA good, accommodation/interested innear objects appears to function well.Health of eyes: normalsize, shape, clarity, structure, pupils. DFEpreviously done
  88. 88. Case Reviews Case #1RecommendationsHigh degree of vision function.Continue to work withdevelopmental therapist. Visualsearch, scan, tracking vertically andhand-eye coordination therapy
  89. 89. Case Reviews Case #2Hx: 2 y 5 mo female, picks up toys more,increased facial expressions, still using g-tube.No change in mobility, feeding improving. Eyehealth unremarkableXT onset after head trauma, all milestonesdelayed shaken baby syndrome, retinal signsresolved, seizures, Prevacid, Topamax,
  90. 90. Case Reviews Case #2phenobarbital, ROS unremarkable except forwhat is noted above. Strong tracking allquadrants, + convergence, +OKN, pupil accresponse, Teller 20/200 50cm, Cardif 20/253at 20 cm, IET, IXT, nystagmus, cyclo +.50-4.00X170 OD +.50-4.00X010 OSDx CVI, strabismus, nystagmusOT/PT/speech/developmental tx
  91. 91. Case Reviews Case #311 yr 6 m F. vision problems noted at 8mos ofage, optic nerve hypoplasia, nystagmusVEP all results delayed. Peak poorly formedbut consistent with optic nervehypoplasia, nystagmusintermittent, gtube, seizures, poorhandeye, Mobility rolls over
  92. 92. Case Reviews Case #3OD +.75-3.00X170 OS +1.00-4.00X010 cycloOKN/Teller UTT, can separate head from eyemovement, IAXT 10 with 5 R hyper, VFUTT, contrast sensitivity UTT, ref +.50-3.25X180 OD, +.75-3.75X015 OS, pupils OD2mm OS 3mm RRL, ocular allergiesPataday Rx’dLight stimulus therapy
  93. 93. Case Reviews Case #42 y/o HM, genetic mutation L1CAM that leadto hydrocephalus and developmental delays,had VP shunt, in early intervention program,no self feeding, hearing ok, Lissencephaly,ROS unremarkable, born c-section because oflarge head, APGAR 9 and 9, no meds
  94. 94. Case Reviews Case #4Teller 20/180, Cardif 20/80, +tracking,+OKN, + eyehand, FROM, Ta 26, 26 lidsheld, +2.25 OD/OS IRET 10PD, PERRL –apdDx: CVI, IAET, Hordeolum, hyperopia, eyehealth unremarkable
  95. 95. 8. Discuss research topics whichfurther the knowledge base ofPCVI.Little research on pure PCVI
  96. 96. Rehabilitation of cortical visual impairment in children. Denise E Malkowicz,Ginette Myers, Gerry Leisman in The International journal of neuroscience(2006)….Criteria were set to extract a fairly homogeneous group of21 children with CVI due to perinatal HIE or postnatal anoxiawho had extensive gray and white matter injury and multipleneurological deficits; 20 of 21 (95%) had symptomaticepilepsy as well. Subjects entered the study with responsesranging from just a pupillary light reflex to rudimentaryperception of outline. Each subject underwent an at-hometreatment program. Twenty of 21 children (95%) manifestedsignificant improvement after 4 to 13 months on theprogram. Results indicate that even in this challenginggroup, there may be considerable neuroplasticity in visualsystems leading to reintegration and visual recovery.
  97. 97. Optom Vis Sci. 2005 Sep;82(9):807-16. Retrospective analysis of refractive errorsin children with vision impairment. Du JW, Schmid KL, Bevan JD, Frater KM,Ollett R, Hein B.….We found that cortical or cerebral vision impairment (CVI) was the mostcommon condition causing vision impairment, accounting for 27.6% of cases.This was followed by albinism (10.6%), retinopathy of prematurity (ROP; 7.0%),optic atrophy (6.2%), and optic nerve hypoplasia (5.3%). Vision impairment wasassociated with ametropia; fewer than 25% of the children had refractive errors< or = +/-1 D. The refractive error frequency plots (for 0 to 2-, 6 to 8-, and 12 to14-year age bands) had a Gaussian distribution indicating that theemmetropization process was abnormal. The mean spherical equivalentrefractive error of the children (n = 813) was +0.78 +/- 6.00 D with 0.94 +/- 1.24D of astigmatism and 0.92 +/- 2.15 D of anisometropia. Most conditions causingvision impairment such as albinism were associated with low amounts ofhyperopia. Moderate myopia was observed in children with ROP.The relative frequency of ocular conditions causing vision impairment inchildren has changed since the 1970s. Children with vision impairment oftenhave an associated ametropia suggesting that theemmetropization system is also impaired.
  98. 98. 9. The use of social media andthe internet to disseminateinformation about PCVI.Websites for information
  99. 99. Cortical Visual Impairment Pediatric Visual Diagnosis FactSheet http://www.aph.org/cvi/articles/bbf_1.htmlCortical Visual Impairmenthttp://www.aapos.org/terms/conditions/40Blind Babies Foundationhttp://blindbabies.org/learn/diagnoses-and-strategies/Perkins: Cortical/Cerebral Visual Impairmenthttp://www.perkins.org/assets/downloads/webinars/cvi-webinar-session-1.pdf
  100. 100. Social Media Pinteresthttp://pinterest.com/pediastaff/visual-impairment/ FacebookPresent Blindness Americanhttps://www.facebook.com/preventblindness?fref=tsThinking Outside the Lightboxhttps://www.facebook.com/Thinkingoutsidethelightbox?ref=ts&fref=ts
  101. 101. Social Media Blogs http://adayinourshoes.com/tag/cortical-visual- impairment/
  102. 102. Resources:Dutton GN, Bax M (eds). Visual Impairment in Children due to Damage to theBrain. Clinics in Developmental Medcine No. 186. Mac Keith Press, London, UK.2010Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patientwith Special Needs; Lippincott Williams & Wilkins. New York, NY. 2012Lantzy C. Cortical Visual Impairment: An Approach to Assessment andIntervention. AFB Press, NY, NY. 2007Hyvarinen L, Jacob N. What and How does this Child See? Vistest, Ltd.Helsinki, Finland. 2011Brown, C. (2004). A guide for teachers and therapists working with my child.Chapel Hill, NC: Early Intervention Training Center for Infants and Toddlers WithVisual Impairments, FPG Child Development Institute, UNC-CH.
  103. 103. ResourcesInternethttp://drleahyvarinen.com/http://Mainosmemos.comhttp://www.slideshare.net/DMAINO/https://www.facebook.com/Thinkingoutsidethelightbox?ref=ts&fref=ts
  104. 104. Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois College of Optometry Lyons Family Eye Care Chicago, Il dmaino@ico.edu ICO.edu LyonsFamilyEyeCare.com MainosMemos.com

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