Cortical M. OD, MEd, FAAO, FCOVD A Visual Impairment Vision in Children with Pediatric Cerebral Visual Impairment 12/7/2015 4 Vision Function and Functional Vision Anomalies in PCV

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Cortical Visual

Impairment

Dominick M. Maino, OD, MEd, FAAO, FCOVD‐A

Professor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois College of Optometry

Lyons Family Eye CareChicago, Il

[email protected]

LyonsFamilyEyeCare.comFB: 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 Pediatric Cerebral Visual Impairment

History of CVI Brain injury 19th century with Phineas P. Gage

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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.


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


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.


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


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 leukomalacia PVL)

Cerebral Visual Impairment now used (especially in Europe)

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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


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 lobe and 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


Determining Vision Function and

Functional Vision in Children with


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Vision Function and Functional Vision Anomalies in PCV

Diagnostic Approaches & Strategies

1.Case History2.Visual Acuity3.Refractive Error4.Vision Function Assessment5.Ocular Health6.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 FunctionEye health

BiomicroscopyTonometryDilated Fundus Evaluation

Special diagnostic toolsEOG (electrooculogram)ERG (electroretinogram)VER/VEP (visually evoked response visual evoked potential)


Functional Vision

Functionally induced disability that overlays pathologically induced disability

Uncorrected refractive error : AmblyopiaConstant Strabismus: Amblyopia Oculomotor dysfunction, Binocular vision dysfunction, Accommodative dysfunction: Attention


Functional vision

Vision information processing (VIP)/ Visual perceptual skills

laterality/directionalityvisual motor integrationnon‐motor perceptual skillsauditory perceptual/processing


Vision Function

Clarity of vision

What is visual acuity? What is contrast sensitivity?What is refractive error?

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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.


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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Vision Function and Functional Vision Anomalies in PCV Vision Function and Functional Vision Anomalies in PCV

Vision Function and Functional Vision Anomalies in PCV Vision Function and Functional Vision Anomalies in PCV

Tests of Visual Acuity and ContrastUsed with permission


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Pursuits, Saccades, Convergence


Retinoscopy

Bell (Apell)

Target(Wolf Wand) directly in front of the retinoscopePatient fixates the target Move the ball toward the patient slowly and smoothlyThe 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).

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

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Treatment with spectacle/lenses

multi‐focal prescription/bifocal

prism

occlusion


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/VisionApps 4 Vision Development

http://www.sovoto.com/group/apps4VisionDevelopment


http://www.wonderbaby.org/articles/cvi‐educational‐tools


Perceptual Learning vs Vision Therapy

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Thinking Outside the LightBox


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. 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


Mental illnesses in children

Pediatric Bipolar disorder

Pediatric depression

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Major environmental hazard: People do not know how to respond

make assumptions

true for lay individuals, teacher, health care professionals

Medication Side Effects

AntidepressantsAbdominal pain/constipation Blurred visionAbnormal dreams/thinking Increased risk of

DisturbancesAnxiety Photophobia


Anticonvulsants

Memory problems/amnesia Blurred visionSedation Dimming of visionInsomnia DiplopiaBronchitis Involuntary eye movementsFluid retention Dry eye


Anti-Parkisons

Abnormal dreams/insomnia Vision abnormalities

Increased muscle tone/weakness Blurred visionInvoluntary movements MydriasisHallucinations Decreased

accommodation


Tranquilizers

Breast development in men Risk of narrow angle GLCBreathing problems Cycloplegia/MydriasisInsomnia Decreased visionTardive dyskinesia Capsular cataract


Anti-anxiety

Anemia Decreased accommodationSeizures NystagmusBlood disorders DiplopiaUnusual excitement Mydriasis

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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, 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.

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

Dominick M. Maino, OD, MEd, FAAO, FCOVD‐AProfessor of Pediatrics/Binocular Vision Illinois Eye Institute

Illinois College of Optometry3241 S. Michigan Ave. Chicago, Il 60616

Lyons Family Eye Care3250 N. Lincoln Ave. Chicago, Il 60657

[email protected]

LyonsFamilyEyeCare.comMainosMemos.com

FB: Vision Therapy at Lyons Family Eye Care

Documents

Cortical M. OD, MEd, FAAO, FCOVD A Visual Impairment Vision in Children with Pediatric Cerebral Visual Impairment 12/7/2015 4 Vision Function and Functional Vision Anomalies in PCV