Lecture Handouts: Pediatric Cortical Visual Impairment

5/23/2014
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Diagnosis and Therapeutic Intervention of Vision Function and Functional Vision Anomalies in PCV
Dominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois College of OptometryLyons Family Eye CareChicago, Il
dmaino@ico.edu
ICO.edu
LyonsFamilyEyeCare.com
MainosMemos.com
Vision Function and Functional Vision Anomalies in PCV
The American Conference on Pediatric Cortical Visual Impairment brings together professionals in optometry, ophthalmology, occupational therapy and visual educational psychology to increase the understanding of the definition, diagnosis and management of cortical vision loss in children.
(Dr Dominick Maino, PCVI Society Founding Board member, Dr. Joseph Maino, Dr. Kerri Pillen)
1. History and Definition of pediatric cortical visual impairment (PCVI).
2. Describe the diagnostic criteria utilized in optometry.
3. Discuss the treatment techniques.
Pediatric Cerebral Visual Impairment
History of CVI
Brain injury 19thcentury with Phineas P. Gage
World War I, wounded veterans with brain injury
Displayed perceived motion in the “blind, non-seeing” visual field.
Ability to sense motion, lights, and colors
Conscious or subconscious.

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Statokinetic dissociation (in children)
greater reduction in sensitivity to stationary visual stimuli relative to similar targets in motion
Riddochphenomenon (adults)
Ability to sense movement even though blind
“See” moving objects…but not stationary ones
Blindsight
Ability to ‘sense’ objects in the way
Statokinetic dissociation (in children)
Movement in the peripheral visual field may elicit a smile in the blind child with quadraplegia and profound intellectual disability.
Children who are fed with a spoon may intermittently open their mouths to receive food when the spoon is moved in an arc from the peripheral visual fields, but not when it approaches the mouth from straight ahead.
Statokineticdissociation (in children)
For those children who understand language stating what is being seen as the child reacts to it may enhance both visual and language development.
Such children may rock to and fro. Whether this generates an image is difficult to know.
Rarely, children with cerebral blindness who are mobile move slowly around obstacles. This phenomenon has been called travel vision (Blindsight).
AlesterlundL, MainoD. That the blind may see: A review: Blindsightand its implications for optometrists. J OptomVis Dev 1999;30(2):86-93
1980’s adults with bilateral occipital cortex insult (cortical blindness)
Term applied to children.
Cortical visual impairment used in the 1980’s onward
Definition of CVI includes injury lateral geniculate nucleus/visual cortex
Reduced visual acuity identifying feature.
Many children damage to white matter surrounding the ventricals (perventricular leukomalaciaPVL)
Cerebral Visual Impairment now used (especially in Europe)
Cerebral visual impairment: inclusive term
Reduced visual acuity
Oculomotor anomalies
Visual field loss
Vision information processing problems
Cognitive Visual Dysfunction (CVD)
Used to identify visual perceptual anomalies
Used to identify vision information processing problems
Cerebral vs Cortical Visual Impairment

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Classification of CVI
Ocular visual impairment: Refractive state. Optics, Eye health
Cerebral visual impairment: Neuro-pathway problems, cortical problems, oculomotor dysfunction, vision information processing (dorsal and ventral streaming processing mechanisms)
The ventral stream(also known as the "what pathway") travels to the temporal lobeand is involved with object identification. The dorsal stream(or, "where pathway") terminates in the parietal lobeand process spatial locations.
Pediatric Cortical Visual Impairment
Reduced visual acuity due to a
“brain problem”
Delayed Visual Maturation (DVM)
DVM type I Visually impaired infants: improved visual abilities by the age of 6 months, often without treatment.
DVM type II: attention problems, associated with neurological/learning abnormalities. Improvement takes longer
DVM III: children have nystagmus, albinism. Vision improves later, can improve to low-normal levels.
DVM IV: associated with retinal,
optic nerve, macular anomalies
Defining Other Disorders and PCVI
Variability with defining disorders not uncommon
Autism rare anomaly
Definition altered so that the number of those on the Spectrumis now considered epidemic
Legal, legislative, health care, insurance issues
Should we be concerned about how PVCI is defined?
Absolutely!
American Association on Intellectual and Developmental Disabilities changed definition of mental retardation
Decreasing IQ cut off point from to 80 to 70
Added adaptive behavior qualifications
Result: instantly cured hundreds of thousands of those with mental retardation/intellectual disability overnight

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What we call a thing is very important
To name it is to have power over it
Determining Vision Function and
Functional Vision in Children with
Diagnostic Approaches & Strategies
1.Case History
2.Visual Acuity
3.Refractive Error
4.Vision Function Assessment
5.Ocular Health
6.Special Tools
Vision Function
Clarity of vision (visual acuity, contrast sensitivity, refractive error)
Oculomotor ability(pursuits and saccades; convergence and divergence)
Accommodation(focusing)
Depth perception (3D vision)
Vision Function
Eye health
Biomicroscopy
Tonometry
Dilated Fundus Evaluation
Special diagnostic tools
EOG(electrooculogram)
ERG(electroretinogram)
VER/VEP(visually evoked response visual evoked potential)
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

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Functional vision
Vision information processing (VIP)/ Visual perceptual skills
laterality/directionality
visual motor integration
non-motor perceptual skills
auditory perceptual/processing
Vision Function
Clarity of vision
What is visual acuity?
What is contrast sensitivity?
What is refractive error?
Vision Function
Clarity of vision
What is visual acuity?
The ability to see a certain size object at a certain distance.
Vision Function
Clarity of vision
What is contrast sensitivity?
Contrast sensitivity measures the ability to see details at low contrast levels. Visual information at low contrast levels is particularly important:
1.in communication, since the faint shadows on our faces carry the visual information related to facial expressions.
2.in orientation and mobility, where we need to see such critical low-contrast forms as the curb, faint shadows, and stairs when walking down. In traffic, the demanding situations are at low contrast levels, for example, seeing in dusk, rain, fog, snow fall, and at night.

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3.in every day tasks, where there are numerous visual tasks at low contrast, like cutting an onion on a light colored surface, pouring coffee into a dark mug, checking the quality of ironing, etc.
4.in near vision tasks like reading and writing, if the information is at low contrast as in poor quality copies or in a fancy, barely readable invitation, etc.
from http://www.lea- test.fi/en/vistests/pediatric/cstests/cstests.html

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Tests of Visual Acuity and Contrast
Used with permission
Pursuits, Saccades, Convergence
Retinoscopy
Book (Getman)
1. At the Free and Easy reading level, the reflex varied from neutral to with motion and
was bright, had sharp edges and had a pinkish color.
2. At the instructional reading level (which was defined as maintaining the reading task
with comprehension in spite of being stressed) the reflex was a varying fast against motion
while the color was bright, sharp, and very pink.
3. At the frustration reading level (which was defined as reading with minimal
comprehension) the reflex showed a slow against motion with a dull brick red color.
Bell (Apell)
Dynamic (#5 & #6 OEP)
MEM (Haynes)
Retinoscopy
Bell (Apell)
Target(Wolf Wand) directly in front of the retinoscope
Patient fixates the target
Move the ball toward the patient slowly and smoothly
The distance of the target from the patient is recorded for a change in motion or other changes of interest
Expect to see a change from “with” to “against” on the way in at 35 -42
cm. (14 -17inches) and a change from “against” to with at 37.5 -45 cm. (15 -18 inches).
MEM (Haynes)
Retinoscopy
Distance retinoscopy(#4) in place
Patient behind the phoropter
Examiner’s retinoscopeat a 20 (twenty) inch distance from the patient.
Patient fixates small letters or a picture
Patient looks, reads, names, and interact visually with the target
Plus spheres added until against motion is seen
Then plus spheres are reduced until the first neutral (no motion) response
Lens in the phoropteris recorded as the “gross” finding.
The #5 retinoscopy, like the other “21 point findings”, had no specific meaning by itself until it was compared to other findings as part of the total analytical examination. The #5, like the 14B gross, will approximate the most plus lens acceptable for near.

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Retinoscopy
MEM Retinoscopy(Monocular Estimation Method)
Patient reads grade appropriate material usually affixed to the retinoscope
Working distance is the patient’s Harmon distance
Quickly “dip” lenses in front of the reading material
A +.25 to +.75 lag of accommodation is considered normal
A high lag would be +1.00 or greater
Accommodative excess would be any AM noted
Also note variability of reflex, color and other variability
Stress Point Retinoscopy
Kraskin& Harmon
For more info see: http://www.oepf.org/VTAids/Retinoscopy.pdf
Retinoscopy
Color vision, copy forms, Matching, Visual Fields
Therapeutic Strategies for the
Treatment of
Treatment begins with the basics.
Vision function
Refractive correction
Spectacles therapeutic
Eye health
Treatment with spectacle/lenses
multi-focal prescription/bifocal
prism
occlusion

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Treatment with spectacle/lenses/computer devices
task specific glasses
high “+” adds (magnification)
Telescopes
Microscopes
Vision Therapy
Oculomotor/hand- eye/accommodation
& fusion
Biocular
Binocular
Integration
Vision Therapy
Integration/Stabilization
Visual stimulation
Vision information processing
Vestibular/Vision
Apps 4 Vision Development
http://www.sovoto.com/group/apps4VisionDevelopment
Perceptual Learning vs Vision Therapy

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Thinking Outside the LightBox
Think Outcomes!
What follows is supplemental information
to the presentation, resources and references that are not necessarily a part of this presentation, but which I thought you would like to have for your own information.
How Do Environmental Factors, Medications and Non-Visual Handicaps Affect the Evaluation and Treatment of Pediatric Cerebral Visual Impairment?
For individuals with disability…
Medications: Prescribed many more medications
Higher affinity for adverse effects due to environmental/systemic factors
Seldom complain of symptoms related to their disability, systemic anomalies, or medication side effects
Alternative and complementary medical therapies
Maino D. Evidence based medicine and CAM: a review. OptomVis Dev2012;43(1):13-17
LemerP. Complementary and Alternative Approaches. In TaubM, BartuccioM, Maino D. Visual Diagnosis and Care of Patients with Special Needs. Lippincott, Williams, Wilkins. 2012
Traditional allopathic approaches

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Mental illnesses in children
Pediatric Bipolar disorder
Pediatric depression
Major environmental hazard: People
do not know how to respond
make assumptions
true for lay individuals, teacher, health care professionals
Medication Side Effects
Antidepressants
Abdominal pain/constipationBlurred vision
Abnormal dreams/thinkingIncreased risk of
Disturbances
AnxietyPhotophobia
Anticonvulsants
Memory problems/amnesiaBlurred vision
SedationDimming of vision
InsomniaDiplopia
BronchitisInvoluntary eye movements
Fluid retentionDry eye
Anti-Parkisons
Abnormal dreams/insomniaVision abnormalities
Increased muscle tone/weaknessBlurred vision
Involuntary movementsMydriasis
HallucinationsDecreased accommodation
Tranquilizers
Breast development in menRisk of narrow angle GLC
Breathing problemsCycloplegia/Mydriasis
InsomniaDecreased vision
Tardive dyskinesiaCapsular cataract

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Anti-anxiety
AnemiaDecreased accommodation
SeizuresNystagmus
Blood disordersDiplopia
Unusual excitementMydriasis
PCVI: References
Dutton GN, BaxM. (eds). Visual impairment in children due to damage to the brain. Clinics in Developmental Medicine. no 186. MacKiethPress. 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
AlesterlundL, Maino D. That the blind may see: A review: Blindsight and its implications for optometrists. J OptomVis Dev 1999;30(2):86-93
KranB. Mayer L. Vision impairment and brain damage. In TaubM, BartuccioM, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:135- 146.
PCVI: References
ColenbranderA. What’s in a name? Appropriate terminology for CVI. J Vis Impair Blind. 2010:583-585
Roman LantzyCA, LantzyA. Outcomes and opportunities: A study of children with cortical visual impairment. J Vis Impair Blind. 2010:649-653.
http://www.aph.org/cvi/define.html
Cerebral Visual Impairment in Periventricular Leukomalacia: MR Correlation: Available from http://www.ajnr.org/content/17/5/979.full.pdf
References
LuekAH. Cortical or cerebral visual impairment in children: A brief overview. J Vis Impair Blind. 2010:585-592.
Woodhouse JM, Maino DM. Down syndrome: In TaubM, BartuccioM, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:31- 40.
Wesson M, Maino D. Oculo-visual findings in Down syndrome, cerebral palsy, and mental retardation with non-specific etiology. In Maino D (ed). Diagnosis and Management of Special Populations. Mosby-Yearbook, Inc. St. Louis, MO. 1995:17-54.
TaubM, ReddellA. Cerebral Palsy. In TaubM, BartuccioM, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:21-30.
References
Ciuffreda K, KapoorN. Acquired brain injury. In TaubM, BartuccioM, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:95-100.
Roman-Lantzy, C. Cortical visual impairment: An approach to assessment and intervention. AFB Press, NY, New York; 2007.
http://www.MainosMemos.com
Resources
Facebook(http://www.facebook.com/Thinkingoutsidethelightbox)
Pinteresthttp://pinterest.com/achampine0302/cortical-visual- impairment-cvi-goodies/
Blogs http://www.MainosMemos.blogspot.com
Apps http://www.sovoto.com/group/apps4VisionDevelopment
Infant Visual Stimulations https://itunes.apple.com/us/app/infant- visual-stimulation/id427443223
Infant Visual Stimulation Video https://www.youtube.com/watch?v=Eyj5PqwUn0w
COVD http://www.COVD.org
OEPF http://www.OEPF.org
Vision Help blog http://visionhelp.wordpress.com/
MainosMemoshttp://www.MainosMemos.blogspot.com

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Dominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular Vision Illinois Eye InstituteIllinois College of Optometry3241 S. Michigan Ave. Chicago, Il 60616Lyons Family Eye Care3250 N. Lincoln Ave. Chicago, Il 60657
dmaino@ico.edu
ICO.edu
LyonsFamilyEyeCare.com
MainosMemos.com

Lecture Handouts: Pediatric Cortical Visual Impairment

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Lecture Handouts: Pediatric Cortical Visual Impairment