Pediatric Cortical Visual Impairment
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor of Pediatrics/Binocular Vision Il...
Presenter Disclosures
Consultant/
Speakers bureaus

Expert Witness/Legal Consultant-Gilbert & Tobin, Sydney, Australia
Ame...
Next PCVIS
Conference:
June 2728, 2014 Oaha, N
E
OD Speakers
include:
Dr. Joseph
Maino, Dr. Curt
Baxstrom, Dr.
Dominick Ma...
4
Case #1
Hx: 2 year 4 mo old, ischemic changes in the
cortex with both white and deep grey matter
diffuse abnormalities, CP...
Pediatric Cortical Visual Impairment

An
Introduction
1. Define pediatric cortical visual impairment (PCVI)
Definition con...
•History of CVI
•Brain injury 19th century
with Phineas P. Gage

7
World War I, wounded
veterans with brain injury
Displayed perceived
motion in the
“blind, non-seeing”
visual field.
Abilit...
•Statokinetic dissociation (in children)
•greater reduction in sensitivity to stationary visual stimuli
relative to simila...
Statokinetic dissociation (in children)

Movement in the peripheral visual field
may elicit a smile in the blind child wit...
•Statokinetic dissociation (in children)

•For those children who understand language
stating what is being seen as the ch...
•1980’s adults with bilateral occipital cortex
insult (cortical blindness)
•Term applied to children.
•Cortical visual imp...
Reduced visual acuity identifying
feature.
Many children damage to white
matter surrounding the ventricals
(perventricular...
Pediatric Cortical Visual Impairment
North America: Cortical Visual Impairment
Elsewhere: Cerebral Visual Impairment
Cereb...
The ventral stream (also known as the
"what pathway") travels to the temporal
lobe and is involved with object
identificat...
•Delayed Visual Maturation (DVM)
•DVM type I Visually impaired infants: improved
visual abilities by the age of 6 months, ...
Pediatric Cortical Visual Impairment Society
Next PCVIS Conference: June 27-28, 2014 Oaha, NE

Congenital or acquired brai...
Pediatric Cortical Visual Impairment

Diagnostic Approaches & Strategies
1.
2.
3.
4.
5.
6.

Case History
Visual Acuity
Ref...
Pediatric Cortical Visual Impairment

Vision Function

Clarity of vision
Oculomotor ability
Accommodation
Binocularity
19
Pediatric Cortical Visual Impairment

Eye health

Biomicroscopy, Tonometry
Dilated Fundus Evaluation
Special diagnostic to...
Pediatric Cortical Visual Impairment

Functional Vision
Functionally induced disability that overlays
pathologically induc...
Pediatric Cortical Visual Impairment

Functional vision

Vision information processing (VIP)/
Visual perceptual skills
lat...
Pediatric Cortical Visual Impairment

History
All the usual questions AND
General/Motor/Visual/Auditory
Development
Daily ...
Pediatric Cortical Visual Impairment

Vision Function

Clarity of vision
What is visual acuity?
What is contrast sensitivi...
Pediatric Cortical Visual Impairment

Vision Function: Clarity of vision

What is visual acuity?

The ability to see a cer...
Pediatric Cortical Visual Impairment

Tests
of
Visual
Acuity

26
27
Pediatric Cortical Visual Impairment

Vision Function:
Clarity of vision

What is contrast sensitivity?

28
Pediatric Cortical Visual Impairment
Contrast sensitivity measures the ability to
see details at low contrast levels. Visu...
Pediatric Cortical Visual Impairment

2. in orientation and mobility, where
we need to see such critical low-contrast
form...
Pediatric Cortical Visual Impairment

3. in every day tasks, where there
are numerous visual tasks at low
contrast, like c...
Pediatric Cortical Visual Impairment

4. in near vision tasks like reading
and writing, if the information is at
low contr...
Pediatric Cortical Visual Impairment

Regular
Contrast

33

Low
Contrast
Pediatric Cortical Visual Impairment
Regular Contrast

34

Low Contrast
Pediatric Cortical Visual Impairment

35
Pediatric Cortical Visual Impairment

36
Pediatric Cortical Visual Impairment

Refractive Error

Myopia (Nearsightedness)
Hyperopia (Farsightedness)
Astigmatism

3...
Pediatric Cortical Visual Impairment

Refractive Error: Assessment
Objective
Dry Retinoscopy
Mohindra Dynamic Retinoscopy
...
Pediatric Cortical Visual Impairment
Refractive Error: Assessment Objective

Mohindra Dynamic Retinoscopy
Dark room
50 cm
...
Objective: Auto-refraction

Pediavision SPOT: See Maino D, Goodfellow G. Tomorrow’s
Practice Today: SPOT On! AOANews 2013;...
Pediatric Cortical Visual Impairment

Refractive Error:
Assessment

Subjective
Which is better 1 or 2?

41
42
Oculomotor ability
basic extra-ocular muscle assessment

EOMs
Pursuits
Saccades
Convergence
Divergence
43
Oculomotor ability
Convergence

44

Divergence
Accommodation
(focusing)
MEM Nott
Book Bell
45
Accommodation (focusing)
Monocular Estimate Method (MEM): you neutralize the
reflex while the patient accommodates to a ta...
Accommodation (focusing)
MEM
Room illumination should be dim but with
target illuminated
Briefly insert lens into line of ...
Accommodation (focusing)
Nott Method: clinician moves toward and
away from the patient until neutrality is
seen (Dioptric ...
Accommodation (focusing)
Book Retinoscopy
Technique developed at the Gesell Institute
by Gerry Getman, OD working with Arn...
Accommodation (focusing)
Book
1. Free and Easy reading level, reflex varied
from neutral to with motion with
bright, sharp...
Accommodation (focusing)
Book
3. Frustration reading level (reading with
minimal comprehension) the reflex showed a
slow a...
Accommodation (focusing)
Bell Retinoscopy
A small shiny bell dangling from a string is used
as a fixation target (now use ...
Accommodation (focusing)
Bell Retinoscopy
The distance between the retinoscope and the
target when the change in motion oc...
54
Color
Vision

55
Binocularity (?)
Fusion
Stereopsis
Depth Perception
(3D vision)

56
Binocularity

57
Eye Health

58
Functional Vision Anomalies in PCV
Amblyopia, Strabismus, Oculomotility Disorder, Accommodative
Disorders, Binocular Visio...
Treatment of Functional Vision Anomalies in PCV

Treatment begins with the basics
Vision function
Refractive error & quali...
Treatment of Functional Vision Anomalies in PCV

Treatment with spectacles
multi-focal prescription/bifocal
prism
occlusio...
Treatment of Functional Vision Anomalies in PCV

Treatment with spectacles
“The medicine in my glasses
has run out!”

62
Treatment of Functional Vision Anomalies in PCV

Vision Therapy/Vision Rehabilitation/
Vision Stimulation

Use Principles ...
Treatment of Functional Vision Anomalies in PCV
Vision Therapy/Vision Rehabilitation/
Vision Stimulation

Principles of
Ne...
Treatment of Functional Vision Anomalies in PCV

Vision Therapy/Vision Rehabilitation/
Vision Stimulation

Use Principles ...
Medications and Alternative Therapies

Medications: Prescribed many more medications
Higher affinity for adverse effects d...
Medications and Alternative Therapies

Alternative and complementary medical
therapies
Maino D. Evidence based medicine an...
Medications and Alternative Therapies

Mental illnesses in children
Pediatric Bipolar disorder/ depression
Schnell PH, Mai...
Medications and Alternative Therapies

Major environmental hazard:
People do not know how to
respond, make assumptions
Thi...
Case Reviews
Children with CVI: Case Reviews

Acknowledgements:
Dr. Tracy Matchinski: The Chicago Lighthouse for People wh...
Case Reviews

Case #1
Hx: 2 year 4 mo old, ischemic changes in the cortex
with both white and deep grey matter diffuse
abn...
Case Reviews

Case #1
Medications: Multiple medications
Participates in vision therapy, developmental tx,
speech/OT/PT, PT...
Case Reviews

Case #1
VF using toys/OKN drum. Responded well in
all visual fields.
Contrast sensitivity at 10% level, mode...
Case Reviews

Case #1
OD +2.50-2.00X005 OS +2.50-2.50X177
Old Rx Mohindra Ret +3.75-2.50X180 OD
+3.50-2,50X180
Near VA goo...
Case Reviews

Case #1

Recommendations
High degree of vision function.
Continue to work with
developmental therapist. Visu...
Case Reviews

Case #2
Hx: 2 y 5 mo female, picks up toys more,
increased facial expressions, still using g-tube.
No change...
Case Reviews

Case #2
phenobarbital, ROS unremarkable except for
what is noted above. Strong tracking all
quadrants, + con...
Case Reviews

Case #3
11 yr 6 m F. vision problems noted at 8mos of
age, optic nerve hypoplasia, nystagmus
VEP all results...
Case Reviews

Case #3
OD +.75-3.00X170 OS +1.00-4.00X010 cyclo
OKN/Teller UTT, can separate head from eye
movement, IAXT 1...
Case Reviews

Case #4
2 y/o HM, genetic mutation L1CAM that lead
to hydrocephalus and developmental delays,
had VP shunt, ...
Case Reviews

Case #4

Teller 20/180, Cardif
20/80, +tracking, +OKN, +
eyehand, FROM, Ta 26, 26 lids
held, +2.25 OD/OS IRE...
Rehabilitation of cortical visual impairment in children. Denise E Malkowicz, Ginette
Myers, Gerry Leisman in The Internat...
Optom Vis Sci. 2005 Sep;82(9):807-16. Retrospective analysis of refractive errors
in children with vision impairment. Du J...
Cortical Visual Impairment Pediatric Visual Diagnosis Fact
Sheet http://www.aph.org/cvi/articles/bbf_1.html
Cortical Visua...
Social Media
Pinterest
http://pinterest.com/pediastaff/visualimpairment/
Facebook
Present Blindness American
https://www.f...
Social Media
Blogs
http://adayinourshoes.com/tag/cortical-visualimpairment/

86
Resources:
Dutton GN, Bax M (eds). Visual Impairment in Children due to Damage to the
Brain. Clinics in Developmental Medc...
Resources
Internet

http://drleahyvarinen.com/

http://Mainosmemos.com
http://www.slideshare.net/DMAINO/
https://www.faceb...
Resources
Internet
This lecture is available from

http://www.slideshare.net/DMAINO/
pediatric-cortical

89
Next PCVIS
Conference:
June 2728, 2014 Oaha, N
E
OD Speakers
include:
Dr. Joseph
Maino, Dr. Curt
Baxstrom, Dr.
Dominick Ma...
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor of Pediatrics/Binocular Vision
Illinois Eye Institute/Illinois College...
Treatment of Functional Vision Anomalies in PCV

Suggestions from members

92
Treatment of Functional Vision Anomalies in PCV
How To Modify your Home for Visual Stimulation
Environment- directly impac...
Treatment of Functional Vision Anomalies in PCV
Increase contrastUse electrical colored tape, stickers, decals to add to o...
Treatment of Functional Vision Anomalies in PCV
Suggested Materials and Activities to tryMobiles- suspend colorful Mylar, ...
Treatment of Functional Vision Anomalies in PCV
Show, Tell & Reach-

Develops understanding of objects and immediate
world...
Treatment of Functional Vision Anomalies in PCV
Show, Tell & Reach- How to do-

Slow down the pace during activities
Routi...
Treatment of Functional Vision Anomalies in PCV
Defined Spaces or Play spacesProvides incentive for movement, exploration,...
Treatment of Functional Vision Anomalies in PCV
Defined Spaces or Play spacesKeep objects predictable and highly meaningfu...
Treatment of Functional Vision Anomalies in PCV
Defined Spaces or Play spacesSittin’ Center- adapted seating with toys sec...
Treatment of Functional Vision Anomalies in PCV
I love … the use of shiny emergency blankets. They are
like large sheets o...
Treatment of Functional Vision Anomalies in PCV

102
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AAO: Pediatric Cortical Visual Impairment

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AAO: Pediatric Cortical Visual Impairment

  1. 1. Pediatric Cortical Visual Impairment Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor of Pediatrics/Binocular Vision Illinois Eye Institute/Illinois College of Optometry Lyons Family Eye Care Chicago, Il dmaino@ico.edu ICO.edu LyonsFamilyEyeCare.com MainosMemos.com Please silence all mobile devices. Unauthorized recording of this session is prohibited. This presentation available at http://www.slideshare.net/DMAINO/pediatric-cortical
  2. 2. Presenter Disclosures Consultant/ Speakers bureaus Expert Witness/Legal Consultant-Gilbert & Tobin, Sydney, Australia American Optometric Association Spokes Person, Lecturer College of Optometrists in Vision Development, Lecturer Pacific University College of Optometry, Lecturer Research funding “No Disclosures.” Stock ownership/Corporate boards-employment “No Disclosures.” Off-label uses Editor/Author “No Disclosures.” Visual Diagnosis and Care of the Patient with Special Needs, Lippincott, 2012; American Optometric Association News 2
  3. 3. Next PCVIS Conference: June 2728, 2014 Oaha, N E OD Speakers include: Dr. Joseph Maino, Dr. Curt Baxstrom, Dr. Dominick Maino
  4. 4. 4
  5. 5. Case #1 Hx: 2 year 4 mo old, ischemic changes in the cortex with both white and deep grey matter diffuse abnormalities, CP spastic quad, DD, seizures since birth (infantile spasms) Case #2 Hx: 2 y 5 mo female, picks up toys more, increased facial expressions, still using g-tube. No change in mobility, feeding improving. Eye health unremarkable XT onset after head trauma, all milestones delayed shaken baby syndrome, retinal signs resolved, seizures, Prevacid, Topamax Case #3 11 yr 6 m F. vision problems noted at 8mos of age, optic nerve hypoplasia, nystagmus VEP all results delayed. Peak poorly formed but consistent with optic nerve hypoplasia, nystagmus intermittent, gtube, seizures, poor handeye, Mobility rolls over 5
  6. 6. Pediatric Cortical Visual Impairment An Introduction 1. Define pediatric cortical visual impairment (PCVI) Definition confusing, misunderstood and imprecise. Pediatric Cerebral Visual Impairment Pediatric Cortical Visual Impairment Delayed Visual Development 6
  7. 7. •History of CVI •Brain injury 19th century with Phineas P. Gage 7
  8. 8. 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. 8
  9. 9. •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 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 9
  10. 10. 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. 10
  11. 11. •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. 11
  12. 12. •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 12
  13. 13. 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) 13
  14. 14. Pediatric Cortical Visual Impairment North America: Cortical Visual Impairment Elsewhere: 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 information processing (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 (available from http://www.slideshare.net/DMAINO/maino-cortical-visual-impairment) 14
  15. 15. 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. 15
  16. 16. •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 16
  17. 17. Pediatric Cortical Visual Impairment Society Next PCVIS Conference: June 27-28, 2014 Oaha, NE Congenital or acquired brain-based visual impairment with onset in childhood, unexplained by an ocular disorder and associated with unique visual and behavioral characteristics. Founding Board: Lindsay Hillier, Alan Lantzy, Richard "Skip" Legge, Dominick Maino, Linda Nobles, Christine Roman, Jacy VerMaas-Lee 17
  18. 18. Pediatric Cortical Visual Impairment Diagnostic Approaches & Strategies 1. 2. 3. 4. 5. 6. Case History Visual Acuity Refractive Error Vision Function Assessment Ocular Health Special Tools Kran B, Mayer L. Visual 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. New York, NY;2012:135-145 18
  19. 19. Pediatric Cortical Visual Impairment Vision Function Clarity of vision Oculomotor ability Accommodation Binocularity 19
  20. 20. Pediatric Cortical Visual Impairment Eye health Biomicroscopy, Tonometry Dilated Fundus Evaluation Special diagnostic tools EOG (electrooculogram) ERG (electroretinogram) VER/VEP (visually evoked response visual evoked potential) 20
  21. 21. Pediatric Cortical Visual Impairment Functional Vision Functionally induced disability that overlays pathologically induced disability Uncorrected refractive error : Amblyopia Constant Strabismus: Amblyopia Oculomotor dysfunction, Binocular vision dysfunction, Accommodative dysfunction: Attention 21
  22. 22. Pediatric Cortical Visual Impairment Functional vision Vision information processing (VIP)/ Visual perceptual skills laterality/directionality visual motor integration non-motor perceptual skills auditory perceptual/processing 22
  23. 23. Pediatric Cortical Visual Impairment History All the usual questions AND General/Motor/Visual/Auditory Development Daily Living Skills Skills needed for Learning 23
  24. 24. Pediatric Cortical Visual Impairment Vision Function Clarity of vision What is visual acuity? What is contrast sensitivity? What is refractive error? 24
  25. 25. Pediatric Cortical Visual Impairment Vision Function: Clarity of vision What is visual acuity? The ability to see a certain size object at a certain distance 25
  26. 26. Pediatric Cortical Visual Impairment Tests of Visual Acuity 26
  27. 27. 27
  28. 28. Pediatric Cortical Visual Impairment Vision Function: Clarity of vision What is contrast sensitivity? 28
  29. 29. Pediatric Cortical Visual Impairment 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. 29
  30. 30. Pediatric Cortical Visual Impairment 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. 30
  31. 31. Pediatric Cortical Visual Impairment 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. 31
  32. 32. Pediatric Cortical Visual Impairment 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.leatest.fi/en/vistests/instruct/contrast/csensiti/csensiti.html 32
  33. 33. Pediatric Cortical Visual Impairment Regular Contrast 33 Low Contrast
  34. 34. Pediatric Cortical Visual Impairment Regular Contrast 34 Low Contrast
  35. 35. Pediatric Cortical Visual Impairment 35
  36. 36. Pediatric Cortical Visual Impairment 36
  37. 37. Pediatric Cortical Visual Impairment Refractive Error Myopia (Nearsightedness) Hyperopia (Farsightedness) Astigmatism 37
  38. 38. Pediatric Cortical Visual Impairment Refractive Error: Assessment Objective Dry Retinoscopy Mohindra Dynamic Retinoscopy CCycloplegic Retinoscopy 38
  39. 39. Pediatric Cortical Visual Impairment Refractive Error: Assessment Objective Mohindra Dynamic Retinoscopy Dark room 50 cm Neutralize main meridians Algebraically add -1.25 to sph 39
  40. 40. Objective: Auto-refraction Pediavision SPOT: See Maino D, Goodfellow G. Tomorrow’s Practice Today: SPOT On! AOANews 2013; March:29 URL 40 http://www.spotvisionscreening.com/2013/
  41. 41. Pediatric Cortical Visual Impairment Refractive Error: Assessment Subjective Which is better 1 or 2? 41
  42. 42. 42
  43. 43. Oculomotor ability basic extra-ocular muscle assessment EOMs Pursuits Saccades Convergence Divergence 43
  44. 44. Oculomotor ability Convergence 44 Divergence
  45. 45. Accommodation (focusing) MEM Nott Book Bell 45
  46. 46. Accommodation (focusing) Monocular Estimate Method (MEM): you neutralize the reflex while the patient accommodates to a target at near (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 46
  47. 47. 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 system The lens that creates neutrality is the value 47
  48. 48. Accommodation (focusing) Nott Method: clinician moves toward and away from the patient until neutrality is seen (Dioptric difference between neutral and your beginning distance is the lead/lag) Against motion: move closer to the patient With motion: move further away from patient 48
  49. 49. Accommodation (focusing) Book Retinoscopy Technique developed at the Gesell Institute by Gerry Getman, OD working with Arnold Gesell, MD. 49
  50. 50. Accommodation (focusing) Book 1. Free and Easy reading level, reflex varied from neutral to with motion with bright, sharp edges and had a pinkish color. 2. Instructional reading level (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. 50
  51. 51. Accommodation (focusing) Book 3. Frustration reading level (reading with minimal comprehension) the reflex showed a slow against motion with a dull brick red color. 51
  52. 52. Accommodation (focusing) Bell Retinoscopy A small shiny bell dangling from a string is used as a fixation target (now use a silver ball on the top of a stick). The ball is moved closer to and farther from the patient along this midline. The retinoscope is positioned slightly above this line at a fixed distance of 50 cm. (20 inches) from the patient. Watch what happens to the reflex as you move the ball. 52
  53. 53. Accommodation (focusing) Bell Retinoscopy The distance between the retinoscope and the target when the change in motion occurs is a physical measure of the lag of accommodation. Typically we 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). http://www.oepf.org/VTAids/Retinoscopy.pdf 53
  54. 54. 54
  55. 55. Color Vision 55
  56. 56. Binocularity (?) Fusion Stereopsis Depth Perception (3D vision) 56
  57. 57. Binocularity 57
  58. 58. Eye Health 58
  59. 59. Functional Vision Anomalies in PCV Amblyopia, Strabismus, Oculomotility Disorder, Accommodative Disorders, Binocular Vision Disorders Lea H, Jacob N. What and how does this child see? Vistest Ltd. Helsinki, Findland;2011. Down Syndrome Review (see Woodhouse M. Maino D. Down Syndrome. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and 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. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs; Lippincott Williams & Wilkins. New York, NY;2012:21-30.) 59
  60. 60. Treatment of Functional Vision Anomalies in PCV Treatment begins with the basics Vision function Refractive error & quality of life Spectacles therapeutic Eye health 60
  61. 61. 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 61
  62. 62. Treatment of Functional Vision Anomalies in PCV Treatment with spectacles “The medicine in my glasses has run out!” 62
  63. 63. 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 63
  64. 64. Treatment of Functional Vision Anomalies in PCV Vision Therapy/Vision Rehabilitation/ Vision Stimulation Principles of Neuroplasticity Time matters Salience matters Age matters Transference Interference 64 Maino D, Donati R, Pange Y, Viola S, Barry S. Neuroplasticity. In Taub M, Bartuccio M, Maino DM. (eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott 2012. Kleim JA, Jones TA. Principles of experience-dependent neural plascitity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51;S22539.
  65. 65. Treatment of Functional Vision Anomalies in PCV Vision Therapy/Vision Rehabilitation/ Vision Stimulation Use Principles of Neuroplasticity Oculomotor/hand-eye, Biocular, Binocular Integration/Stabilization, Visual stimulation, Vision information processing, Vestibular/Vision Computer applications 65
  66. 66. Medications and Alternative Therapies Medications: Prescribed many more medications Higher affinity for adverse effects due to systemic/environmental factors Seldom complain of symptoms related to their disability, systemic anomalies, or medication side effects RJ Donati RJ, Maino DM, Bartell H, Kieffer M. Polypharmacy and the Lack of Oculo-Visual Complaints from those with Mental Illness and Dual Diagnosis. Optometry 2009;80:249-254 66
  67. 67. Medications and Alternative Therapies Alternative and complementary medical therapies Maino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13-17 Traditional allopathic approaches 67
  68. 68. Medications and Alternative Therapies Mental illnesses in children Pediatric Bipolar disorder/ depression Schnell PH, Maino D, Jespersen R. Psychiatric Illness and Associated Oculo-visual Anomalies. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs; Lippincott Williams & Wilkins. New York, NY;2012:111-124. 68
  69. 69. Medications and Alternative Therapies Major environmental hazard: People do not know how to respond, make assumptions This is true for lay individuals, teachers, health care professionals 69
  70. 70. Case Reviews Children with CVI: Case Reviews Acknowledgements: Dr. Tracy Matchinski: The Chicago Lighthouse for People who are Blind or Visually Impaired Dr. Mary Flynn-Roberts: Illinois Eye Institute/Illinois College of Optometry Electrodiagnostic Service Movies, etc. Hyvarinen L, Jacob N. What and How does this Child See? Vistest, Ltd. Helsinki, Finland. 2011 70
  71. 71. Case Reviews Case #1 Hx: 2 year 4 mo old, ischemic changes in the cortex with both white and deep grey matter diffuse abnormalities, CP spastic quad, DD, seizures since birth (infantile spasms), Placental umbilical cord problems Dx: CVI, Delayed visual maturation, exotropia., lower heart rate, meconium aspiration, profound hearing loss bilateral cochlear implants, encephalopathy 71
  72. 72. Case Reviews Case #1 Medications: Multiple medications Participates in vision therapy, developmental tx, speech/OT/PT, PT pool, VA 20/300 PL Teller Cards, 38 cm test dist. OU Horizontal tracking fine, vertical much more difficult Binocularity inadequate most of the time, IAXT 3035PD 72
  73. 73. Case Reviews Case #1 VF using toys/OKN drum. Responded well in all visual fields. Contrast sensitivity at 10% level, moderately reduced for his age Refraction hyperopia/astigmatism. Tolerates glasses well. No change from last prescription. 73
  74. 74. Case Reviews Case #1 OD +2.50-2.00X005 OS +2.50-2.50X177 Old Rx Mohindra Ret +3.75-2.50X180 OD +3.50-2,50X180 Near VA good, accommodation/interested in near objects appears to function well. Health of eyes: normal size, shape, clarity, structure, pupils. DFE previously done 74
  75. 75. Case Reviews Case #1 Recommendations High degree of vision function. Continue to work with developmental therapist. Visual search, scan, tracking vertically and hand-eye coordination therapy 75
  76. 76. Case Reviews Case #2 Hx: 2 y 5 mo female, picks up toys more, increased facial expressions, still using g-tube. No change in mobility, feeding improving. Eye health unremarkable XT onset after head trauma, all milestones delayed shaken baby syndrome, retinal signs resolved, seizures, Prevacid, Topamax, 76
  77. 77. Case Reviews Case #2 phenobarbital, ROS unremarkable except for what is noted above. Strong tracking all quadrants, + convergence, +OKN, pupil acc response, Teller 20/200 50cm, Cardif 20/253 at 20 cm, IET, IXT, nystagmus, cyclo +.504.00X170 OD +.50-4.00X010 OS Dx CVI, strabismus, nystagmus OT/PT/speech/developmental tx 77
  78. 78. Case Reviews Case #3 11 yr 6 m F. vision problems noted at 8mos of age, optic nerve hypoplasia, nystagmus VEP all results delayed. Peak poorly formed but consistent with optic nerve hypoplasia, nystagmus intermittent, gtube, seizures, poor handeye, Mobility rolls over 78
  79. 79. Case Reviews Case #3 OD +.75-3.00X170 OS +1.00-4.00X010 cyclo OKN/Teller UTT, can separate head from eye movement, IAXT 10 with 5 R hyper, VF UTT, contrast sensitivity UTT, ref +.50-3.25X180 OD, +.75-3.75X015 OS, pupils OD 2mm OS 3mm RRL, ocular allergies Pataday Rx’d Light stimulus therapy 79
  80. 80. Case Reviews Case #4 2 y/o HM, genetic mutation L1CAM that lead to hydrocephalus and developmental delays, had VP shunt, in early intervention program, no self feeding, hearing ok, Lissencephaly, ROS unremarkable, born c-section because of large head, APGAR 9 and 9, no meds 80
  81. 81. Case Reviews Case #4 Teller 20/180, Cardif 20/80, +tracking, +OKN, + eyehand, FROM, Ta 26, 26 lids held, +2.25 OD/OS IRET 10PD, PERRL – apd Dx: CVI, IAET, Hordeolum, hyperopia, eye health unremarkable 81
  82. 82. 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 of 21 children with CVI due to perinatal HIE or postnatal anoxia who had extensive gray and white matter injury and multiple neurological deficits; 20 of 21 (95%) had symptomatic epilepsy as well. Subjects entered the study with responses ranging from just a pupillary light reflex to rudimentary perception of outline. Each subject underwent an at-home treatment program. Twenty of 21 children (95%) manifested significant improvement after 4 to 13 months on the program. Results indicate that even in this challenging group, there may be considerable neuroplasticity in visual systems leading to reintegration and visual recovery. 82
  83. 83. Optom Vis Sci. 2005 Sep;82(9):807-16. Retrospective analysis of refractive errors in 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 most common 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 was associated with ametropia; …. The mean spherical equivalent refractive error of the children (n = 813) was +0.78 +/- 6.00 D with 0.94 +/- 1.24 D of astigmatism and 0.92 +/- 2.15 D of anisometropia. ….. The relative frequency of ocular conditions causing vision impairment in children has changed since the 1970s. Children with vision impairment often have an associated ametropia suggesting that the emmetropization system is also impaired. 83
  84. 84. Cortical Visual Impairment Pediatric Visual Diagnosis Fact Sheet http://www.aph.org/cvi/articles/bbf_1.html Cortical Visual Impairment http://www.aapos.org/terms/conditions/40 Blind Babies Foundation http://blindbabies.org/learn/diagnoses-and-strategies/ Perkins: Cortical/Cerebral Visual Impairment http://www.perkins.org/assets/downloads/webinars/cvi -webinar-session-1.pdf 84
  85. 85. Social Media Pinterest http://pinterest.com/pediastaff/visualimpairment/ Facebook Present Blindness American https://www.facebook.com/preventblindness?fre f=ts Thinking Outside the Lightbox https://www.facebook.com/Thinkingoutsidetheligh tbox?ref=ts&fref=ts 85
  86. 86. Social Media Blogs http://adayinourshoes.com/tag/cortical-visualimpairment/ 86
  87. 87. Resources: Dutton GN, Bax M (eds). Visual Impairment in Children due to Damage to the Brain. Clinics in Developmental Medcine No. 186. Mac Keith Press, London, UK. 2010 Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs; Lippincott Williams & Wilkins. New York, NY. 2012 Lantzy C. Cortical Visual Impairment: An Approach to Assessment and Intervention. AFB Press, NY, NY. 2007 Hyvarinen L, Jacob N. What and How does this Child See? Vistest, Ltd. Helsinki, Finland. 2011 Brown, C. (2004). A guide for teachers and therapists working with my child. Chapel Hill, NC: Early Intervention Training Center for Infants and Toddlers With Visual Impairments, FPG Child Development Institute, UNC-CH. 87
  88. 88. Resources Internet http://drleahyvarinen.com/ http://Mainosmemos.com http://www.slideshare.net/DMAINO/ https://www.facebook.com/Thinking outsidethelightbox?ref=ts&fref=ts 88
  89. 89. Resources Internet This lecture is available from http://www.slideshare.net/DMAINO/ pediatric-cortical 89
  90. 90. Next PCVIS Conference: June 2728, 2014 Oaha, N E OD Speakers include: Dr. Joseph Maino, Dr. Curt Baxstrom, Dr. Dominick Maino
  91. 91. Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor of Pediatrics/Binocular Vision Illinois Eye Institute/Illinois College of Optometry Lyons Family Eye Care Chicago, Il 91 dmaino@ico.edu ICO.edu LyonsFamilyEyeCare.com MainosMemos.com
  92. 92. Treatment of Functional Vision Anomalies in PCV Suggestions from members 92
  93. 93. Treatment of Functional Vision Anomalies in PCV How To Modify your Home for Visual Stimulation Environment- directly impacts visual development and brain cells Lighting- to increase stimulation of brain cells Open drapes- position child’s back to windows/doors Use In-direct lighting – floor or desks lamps are best and reduce glare (direct light may damage retinal tissues); compact fluorescent bulbs -16 or 22 Watt with warm color 93
  94. 94. Treatment of Functional Vision Anomalies in PCV Increase contrastUse 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 play spaces 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 94
  95. 95. Treatment of Functional Vision Anomalies in PCV Suggested Materials and Activities to tryMobiles- suspend colorful Mylar, CD’s, strings- provides movement and shiny objects Screen savers- computer backgrounds are very stimulating and can become a cause and effect activity Household items- use soup cans, quacker oats containers, spoons, metal bowls, colorful cups Adhesives- wall decals, stickers; add to lower places on walls **Be aware of what you wear or what other sounds are in the environment; competing stimuli make it harder to visually attend and focus Barbara Halton-Bailey, Education Coordinator Virginia Dept. f/t Blind 95
  96. 96. Treatment of Functional Vision Anomalies in PCV Show, Tell & Reach- Develops understanding of objects and immediate world through hands on experience Helps understand daily routines Develops better visual and/or motor responses Builds sound localization Increases active involvement Lays the groundwork for crawling and walking 96
  97. 97. Treatment of Functional Vision Anomalies in PCV Show, Tell & Reach- How to do- Slow down the pace during activities Routinely take 5 minutes or so; tell what object is and what is happening, allow extra time for baby to “study” with hands, ears, eyes and body Provide assistance with reaching Babies may need to hold and “get to know” it by touching it before understanding and reaching for it away from the body Gradually put familiar toys a few inches away (after initially touching) and make a sound for baby to reach for the object Barbara Halton-Bailey, Education Coordinator Virginia Dept. f/t Blind 97
  98. 98. Treatment of Functional Vision Anomalies in PCV Defined Spaces or Play spacesProvides incentive for movement, exploration, and independent interaction A life-long organizational strategy to enhance efficiency of movement, independence and self-esteem-the use of defined spaces expands and grows with the child Use walls and furniture as reference points in each room of the house First place toys touching body as baby plays on tummy, back, side or seated on the play space. Move objects further away and make sounds with the object for baby to reach for 98
  99. 99. Treatment of Functional Vision Anomalies in PCV Defined Spaces or Play spacesKeep objects predictable and highly meaningful to the child in each area Be sure objects are easily accessible with the child’s current abilities Return child to the play space frequently showing where 2 or 3 toys are, throughout the day and allow the child to play independently Examples: Floor space- pallet with a border on 2-3 sides created by walls, furniture Pull-up space- arranged beside sofa, chairs, shelves, tables Crib- use only if child enjoys waking periods in the crib 99
  100. 100. Treatment of Functional Vision Anomalies in PCV Defined Spaces or Play spacesSittin’ Center- adapted seating with toys secured within reach beside, in front, and above Eatin’ place- High chair, tray table-arrange cup and bowl Kitchen space- special cabinet designated and marked, containing child-safe pots. Lids containers, spoons Outer space- area in backyard defined by play equipment, furniture, garden fencing, wind chimes. Have predictable storage of outdoor toys, wheeled vehicles, push carts, radio or music used as a sound source to return to the door. Barbara Halton-Bailey, TVI, NBCT Education Coordinator, DBVI 100
  101. 101. Treatment of Functional Vision Anomalies in PCV I love … the use of shiny emergency blankets. They are like large sheets of reflective Mylar material that kids love to wrap themselves in and look at the reflection of the light off of the wrinkles created in the sheets. ….reflective Christmas gift bags, water bottles filled with glitter, snap and light up neon bracelets or necklaces, pompoms, shiny reflective beaded necklaces, feather boas and the list goes on and on. Sometimes just using neon coloured duct tape over a baby bottle or favorite toy works wonders. Jody Whelan, Specialist, Early Intervention Early Childhood Vision Consultant Northeast Blind Low Vision Early Intervention Program 101
  102. 102. Treatment of Functional Vision Anomalies in PCV 102

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