Pediatric Cortical Visual Impairment
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This course presents the latest information concerning cortical visual impairment, its etiology, diagnosis and treatment. Various topics reviewed include cortical vs cerebral visual impairment, ventral/dorsal visual streams, visual acuity, and contrast sensitivity. Also discussed are various retinoscopy techniques, overlapping functional vision disorders, and visual stimulation/therapy for these disorders. Course Objectives At the end of this course, the participant will: Be able to identify cortical vs cerebral visual impairment Be able to access various vision functions such as visual acuity, contrast sensitivity, oculomotor and accommodative disorders Be able to treat the diagnosed vision problems with all the tools available to the optometrist (spectacles, low vision devices, vision rehabilitative techniques) Be aware of and use outside resources to supplement and add to any therapeutic interventions recommended
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Pediatric Cortical Visual Impairment
- 1. 4/8/2016 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 FB: Vision Therapy at Lyons Family Eye Care Pediatric Cortical Visual Impairment Society 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. Drs. Dominick Maino, Joseph Maino, Kerri Pillen, Curt Baxsrom, Beth Ballinger, Nicole Hooper have all participated. Cortical Visual Impairment Kran B, Mayer L. Vision Impairment and Brain Damage Ciuffreda K, Kapoor N. Acquired brain injury. Both 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 Cortical Visual Impairment
- 2. 4/8/2016 2 Pediatric Cerebral Visual Impairment History of CVI Brain injury 19th century with Phineas P. Gage 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. 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 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. 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 (Blindsight). Alesterlund L, Maino D. That the blind may see: A review: Blindsight and its implications for optometrists. J Optom Vis Dev 1999;30(2):86‐93 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
- 3. 4/8/2016 3 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) 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 Cerebral vs Cortical Visual Impairment 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) Pediatric Cerebral Visual Impairment 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. Pediatric Cortical Visual Impairment Reduced visual acuity due to a “brain problem” 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
- 4. 4/8/2016 4 Pediatric Cerebral Visual Impairment Determining Vision Function and Functional Vision in Children with Pediatric Cerebral Visual Impairment 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 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) 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) Vision Function and Functional Vision Anomalies in PCV 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 Vision Function and Functional Vision Anomalies in PCV Functional vision Vision information processing (VIP)/ Visual perceptual skills laterality/directionality visual motor integration non‐motor perceptual skills auditory perceptual/processing
- 5. 4/8/2016 5 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? 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. Vision Function and Functional Vision Anomalies in PCV Vision Function Clarity of vision What is contrast sensitivity? 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. 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. 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.
- 8. 4/8/2016 8 Pediatric Cerebral Visual Impairment Treatment begins with the basics. Vision function Refractive correction Spectacles therapeutic Eye health Pediatric Cerebral Visual Impairment Treatment with spectacle/lenses multi‐focal prescription/bifocal prism occlusion Pediatric Cerebral Visual Impairment Treatment with spectacle/lenses/computer devices task specific glasses high “+” adds (magnification) Telescopes Microscopes Pediatric Cerebral Visual Impairment Vision Therapy Oculomotor/hand‐ eye/accommodation & fusion Biocular Binocular Integration 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 Pediatric Cerebral Visual Impairment http://www.wonderbaby.org/articles/cvi ‐educational‐tools
- 9. 4/8/2016 9 Pediatric Cerebral Visual Impairment Perceptual Learning vs Vision Therapy Pediatric Cerebral Visual Impairment Thinking Outside the LightBox Pediatric Cerebral Visual Impairment 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. Pediatric Cerebral Visual Impairment How Do Environmental Factors, Medications and Non‐Visual Handicaps Affect the Evaluation and Treatment of Pediatric Cerebral Visual Impairment? 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 Pediatric Cerebral Visual Impairment Alternative and complementary medical therapies Maino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13‐17 Lemer P. Complementary and Alternative Approaches. In Taub M, Bartuccio M, Maino D. Visual Diagnosis and Care of Patients with Special Needs. Lippincott, Williams, Wilkins. 2012 Traditional allopathic approaches
- 10. 4/8/2016 10 Pediatric Cerebral Visual Impairment Mental illnesses in children Pediatric Bipolar disorder Pediatric depression Pediatric Cerebral Visual Impairment Major environmental hazard: People do not know how to respond make assumptions true for lay individuals, teacher, health care professionals Medication Side Effects Antidepressants Abdominal pain/constipation Blurred vision Abnormal dreams/thinking Increased risk of Disturbances Anxiety Photophobia Medication Side Effects Anticonvulsants Memory problems/amnesia Blurred vision Sedation Dimming of vision Insomnia Diplopia Bronchitis Involuntary eye movements Fluid retention Dry eye Medication Side Effects Anti-Parkisons Abnormal dreams/insomnia Vision abnormalities Increased muscle tone/weakness Blurred vision Involuntary movements Mydriasis Hallucinations Decreased accommodation Medication Side Effects Tranquilizers Breast development in men Risk of narrow angle GLC Breathing problems Cycloplegia/Mydriasis Insomnia Decreased vision Tardive dyskinesia Capsular cataract
- 11. 4/8/2016 11 Medication Side Effects Anti-anxiety Anemia Decreased accommodation Seizures Nystagmus Blood disorders Diplopia Unusual excitement Mydriasis PCVI: References Dutton GN, Bax M. (eds). Visual impairment in children due to damage to the brain. Clinics in Developmental Medicine. no 186. MacKieth Press. London;2010. Strategies for dealing with visual problems due to cerebral visual impairment: Gillian McDaid, Debbie Cockburn, Gordon N Dutton available from http://www.ssc.education.ed.ac.uk/courses/vi&multi/vjan08i.html Alesterlund L, Maino D. That the blind may see: A review: Blindsight and its implications for optometrists. J Optom Vis Dev 1999;30(2):86‐93 Kran B. Mayer L. Vision impairment and brain damage. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:135‐ 146. PCVI: References Colenbrander A. What’s in a name? Appropriate terminology for CVI. J Vis Impair Blind. 2010:583‐585 Roman Lantzy CA, Lantzy A. Outcomes and opportunities: A study of children with cortical visual impairment. J Vis Impair Blind. 2010:649‐653. http://www.aph.org/cvi/define.html Cerebral Visual Impairment in Periventricular Leukomalacia: MR Correlation: Available from http://www.ajnr.org/content/17/5/979.full.pdf References Luek AH. Cortical or cerebral visual impairment in children: A brief overview. J Vis Impair Blind. 2010:585‐592. Woodhouse JM, Maino DM. Down syndrome: In Taub M, 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. References Ciuffreda K, Kapoor N. Acquired brain injury. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:95‐100. Roman‐Lantzy, C. Cortical visual impairment: An approach to assessment and intervention. AFB Press, NY, New York; 2007. http://www.MainosMemos.blogspot.com Pediatric Cerebral Visual Impairment Resources Facebook (http://www.facebook.com/Thinkingoutsidethelightbox) Pinterest http://pinterest.com/achampine0302/cortical‐visual‐ impairment‐cvi‐goodies/ Blogs http://www.MainosMemos.blogspot.com Apps http://www.sovoto.com/group/apps4VisionDevelopment Infant Visual Stimulations https://itunes.apple.com/us/app/infant‐ visual‐stimulation/id427443223 Infant Visual Stimulation Video https://www.youtube.com/watch?v=Eyj5PqwUn0w COVD http://www.COVD.org OEPF http://www.OEPF.org Vision Help blog http://visionhelp.wordpress.com/ MainosMemos http://www.MainosMemos.blogspot.com