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American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
American Conference on Pediatric Cerebral Visual Impairment
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American Conference on Pediatric Cerebral Visual Impairment

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My presentation at the American Conference on Pediatric Visual Impairment. Childrens Hospital Omaha, NE

My presentation at the American Conference on Pediatric Visual Impairment. Childrens Hospital Omaha, NE

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  • 1. A National Conference onThe Evaluation and Treatment ofPediatric Cerebral Visual ImpairmentThe Children’s Hospital andMedical Center of Omaha, NE
  • 2. Dominick M. Maino, O.D., M.Ed., F.A.A.O. Professor, Pediatrics/Binocular Vision Service Illinois College of Optometry Illinois Eye Institute 3241 S. Michigan Ave. Chicago, Il. 60616 312-949-7280 (Voice) 312-949-7358 (fax) dmaino@ico.edu www.ico.edu LyonsFamilyEyeCare.com MainosMemos.blogspot.com
  • 3. The Child with Special Needs A Brief Overview
  • 4. The Patient with Special Needs
  • 5. Individuals with Special NeedsCerebral Palsy AutismDown Syndrome Intellectual DisabilityFragile X Syndrome Brain InjuryPsychiatric Illness ….and…. Pediatric Cerebral Visual Impairment
  • 6. Pediatric Cerebral Visual Impairment• 1. Defining Pediatric Cerebral Visual Impairment• Definition confusing, misunderstood and imprecise. • Pediatric Cerebral Visual Impairment (PCVI). • Pediatric Cortical Visual Impairment • Delayed Visual Development
  • 7. Pediatric Cerebral Visual Impairment• North America •Cortical Visual Impairment• Elsewhere •Cerebral Visual Impairment
  • 8. Pediatric Cerebral Visual Impairment • History of CVI • Brain injury 19th century with Phineas P. Gage
  • 9. Pediatric Cerebral Visual Impairment• 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.
  • 10. Pediatric Cerebral Visual Impairment• 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
  • 11. Pediatric Cerebral Visual Impairment • 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.
  • 12. Pediatric Cerebral Visual Impairment • 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.
  • 13. Pediatric Cerebral Visual Impairment• 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
  • 14. Pediatric Cerebral Visual Impairment•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)
  • 15. Pediatric Cerebral Visual Impairment• 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
  • 16. Pediatric Cerebral Visual Impairment• 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)
  • 17. Pediatric Cerebral Visual ImpairmentThe ventral stream (also known as the "what pathway")travels to the temporal lobe and is involved with objectidentification. The dorsal stream (or, "where pathway")terminates in the parietal lobe and process spatial locations.
  • 18. Pediatric Cerebral Visual Impairment• 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
  • 19. Pediatric Cerebral Visual Impairment• 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
  • 20. Pediatric Cerebral Visual Impairment • 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
  • 21. Pediatric Cerebral Visual ImpairmentWhat we call a thing is very importantTo name it is to have power over it
  • 22. 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.
  • 23. 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
  • 24. Pediatric Cerebral Visual Impairment Determining Vision Function and Functional Vision in Children withPediatric Cerebral Visual Impairment
  • 25. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment • Need to assess vision function and functional vision • Vision function •Clarity of vision (visual acuity, contrast sensitivity, refractive error, Amblyopia)
  • 26. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment • Oculomotor ability (pursuits and saccades; convergence and divergence, strabismus) •Pursuits/Visual Tracking •Saccades
  • 27. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment • Binocular Vision • Convergence insufficiency/excess • Divergence insufficiency/excess • Strabismus • Exotropia • Esotropia • Hypertropia
  • 28. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment • Accommodation (focusing) • Accommodative insufficiency • Accommodative excess • Ill-sustained accommodation • Accommodative instability
  • 29. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment • Depth perception (3D vision)• Binocular vision (Stereoscopy) is the ability to align and focus both eyes accurately on an object and then combine the visual images from each eye into a single, clear, three dimensional perception. Difficulty seeing in 3D can arise when eye fatigue occurs, forcing the eyes to make adjustments to focus simultaneously on images that are near and far away.• Symptoms indicating a potential problem viewing images in 3D can vary, but some common symptoms include headaches, blurred vision, nausea and dizziness.
  • 30. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment• Eye health • Cornea, lens, pupil, • iris, vitreous, optic nerve, • retina• Visual Cortex• Other areas of the brain (motor,• executive function)
  • 31. Pediatric Cerebral Visual ImpairmentDetermining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment• Special diagnostic tools • EOG (electrooculogram) • ERG (electroretinogram) • VER/VEP (visually evoked response visual evoked potential)
  • 32. Pediatric Cerebral Visual Impairment Vision Function of Children with DisabilityDown Syndrome: Visual Acuity, Refractive Error, Strabismus/Oculomotor, Accommodation, Ocular health, Vision Information Processing, OtherCerebral Palsy: Visual Acuity, Refractive Error, Strabismus/Oculomotor, Accommodation, Ocular Health, Vision Information Processing, OtherBrain Injury: Visual Acuity, Refractive Error, Strabismus/Oculomotor, Accommodation, Ocular Health, Vision Information Processing, Other
  • 33. Pediatric Cerebral Visual Impairment Functional vision Functionally induced disability that overlays pathologically induced disability • Uncorrected refractive error • Amblyopia • On top of vision loss due • to cerebral impairment • Down Syndrome • Cerebral Palsy
  • 34. Pediatric Cerebral Visual Impairment• Vision information processing (VIP)/Visual perceptual skills • Laterality/Directionality • Visual motor integration • Non-motor perceptual skills • Auditory perceptual/processing
  • 35. References• Luek AH. Cortical or cerebral visual impairment in children: A brief overview. J Vis Impair Blind. 2010:585-592.• Woodhouse JM, Maino DM. Down syndrome: In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:31-40.• Wesson M, Maino D. Oculo-visual findings in Down syndrome, cerebral palsy, and mental retardation with non-specific etiology. In Maino D (ed). Diagnosis and Management of Special Populations. Mosby-Yearbook, Inc. St. Louis, MO. 1995:17-54.• Taub M, Reddell A. Cerebral Palsy. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:21-30.
  • 36. References• Ciuffreda K, Kapoor N. Acquired brain injury. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:95-100.• Roman-Lantzy, C. Cortical visual impairment: An approach to assessment and intervention. AFB Press, NY, New York; 2007.• http://www.3deyehealth.org/• http://www.MainosMemos.blogspot.com
  • 37. Pediatric Cerebral Visual Impairment Therapeutic Strategies for the Treatment ofPediatric Cerebral Visual Impairment
  • 38. Pediatric Cerebral Visual Impairment• Treatment begins with the basics. •Vision function •Refractive correction •Spectacles therapeutic •Eye health
  • 39. Pediatric Cerebral Visual Impairment• Treatment with spectacle/lenses • multi-focal prescription/bifocal • prism • occlusion
  • 40. Pediatric Cerebral Visual Impairment• Treatment with spectacle/lenses • task specific glasses • high “+” adds (magnification) • Telescopes • Microscopes
  • 41. Pediatric Cerebral Visual Impairment• Vision Therapy • Oculomotor/hand- eye/accommodation & fusion • Biocular • Binocular
  • 42. Pediatric Cerebral Visual Impairment• Vision Therapy • Integration/Stabilization • Visual stimulation • Vision information processing • Vestibular/Vision Apps 4 Vision Development http://www.sovoto.com/group/apps4VisionDevelopment
  • 43. Pediatric Cerebral Visual Impairment• Resources • Facebook (http://www.facebook.com/Thinkingoutsidet helightbox) • Pinterest http://pinterest.com/achampine0302/cortic al-visual-impairment-cvi-goodies/ • Blogs http://www.MainosMemos.blogspot.com
  • 44. Pediatric Cerebral Visual Impairment Thinking Outside the LightBox
  • 45. Pediatric Cerebral Visual ImpairmentHow Do Environmental Factors, Medications and Non-Visual Handicaps Affect the Evaluation and Treatment of Pediatric Cerebral Visual Impairment?
  • 46. Pediatric Cerebral Visual ImpairmentFor 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
  • 47. Pediatric Cerebral Visual Impairment• Alternative and complementary medical therapiesMaino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13-17Lemer 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
  • 48. Pediatric Cerebral Visual Impairment• Mental illnesses in children • Pediatric Bipolar disorder • Pediatric depression
  • 49. Pediatric Cerebral Visual Impairment • Major environmental hazard: People • do not know how to respond • make assumptions • true for lay individuals, teacher, health care professionals• Other
  • 50. Medication Side EffectsAntidepressants Abdominal pain/constipation Blurred vision Abnormal dreams/thinking Increased risk of Glaucoma Abnormal ejaculation/orgasm Visual Disturbances Anxiety Photophobia
  • 51. Medication Side EffectsAnticonvulsants Memory problems/amnesia Blurred vision Sedation Dimming of vision Insomnia Diplopia Bronchitis Involuntary eye movements Fluid retention Dry eye
  • 52. Medication Side EffectsAnti-Parkisons Abnormal dreams/insomnia Vision abnormalities Increased muscle tone/weakness Blurred vision Involuntary movements Mydriasis Hallucinations Decreased accommodation
  • 53. Medication Side EffectsTranquilizers Breast development in men Risk of narrow angle GLC Breathing problems Cycloplegia/Mydriasis Insomnia Decreased vision Tardive dyskinesia Capsular cataract
  • 54. Medication Side EffectsAnti-anxiety Anemia Decreased accommodation Seizures Nystagmus Blood disorders Diplopia Unusual excitement Mydriasis
  • 55. Dominick M. Maino, O.D., M.Ed., F.A.A.O. Professor, Pediatrics/Binocular Vision Service Illinois College of Optometry Illinois Eye Institute 3241 S. Michigan Ave. Chicago, Il. 60616 312-949-7280 (Voice) 312-949-7358 (fax) dmaino@ico.edu www.ico.edu LyonsFamilyEyeCare.com MainosMemos.blogspot.com

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