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Diagnosis and Management:P ti t ith S i l N dPatients with Special Needs

Dominick M. Maino, O.D., M.Ed., F.A.A.O.

Professor, Pediatrics/Binocular Vision Service

Illinois College of OptometryIllinois Eye Institute

3241 S. Michigan Ave.Chicago, Il. 60616

312-949-7280 (Voice) 312-949-7358 (fax)

dmaino@ico.eduwww.ico.edu nw.optometry.net

Diagnosis

Assessment Techniques for Special Populations

Use everything you know, be creative, and trust your objective evaluation skills!

Diagnosis

• Preparing for the examination• greet patient by name• position yourself at patient’s eye

level• be on schedulebe on schedule• consider patient’s wishes about

family/friends in exam room• direct initial comments to patient• treat patient as a person first, then

as an individual with a disability

Diagnosis

• Preparing for the examination• speak clearly• listen carefully• use short command sentences

• “look here”• “look here”• “do this”• “watch my light”

Treat the patient the way you would want to be treated!

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Remember the 10 Commandments

1.) Speak directly to the person rather than thru a companion or sign language interpreter.

2.)Always offer to shake

4.) If you offer assistance wait until the offer is accepted, then listen and wait for instructions.

5 ) Treat adults as adults) yhands when introduced.

3.)Always identify yourself and others who are with you when meeting someone who is blind.

5.) Treat adults as adults.

6.) Do not lean against or hand on someone's wheelchair or cart.

Remember the 10 Commandments

7.) Listen attentively when talking to people who have difficulty speaking and wait for them to finish.

8.) Place yourself at eye level when talking to someone in a

10.) Relax. Don’t be embarrassed if you use common expressions that seems torelate to a person’s disability.

when talking to someone in a wheelchair.

9.) Tap a person who is deaf on the shoulder or wave your hand to get their attention.

The Ten Commandments of Communicating with People With Disabilities

Case History Case History

• Demographic Information

• Medical history including their disability• typically taking many medications

• Visual history

• Educational history• Educational history

• Rehabilitation history

• Vocational history

• Recreational history

Visual Acuity

•Use highest level possible

•binocular before monocular testing

•adaptive positioning

•use assistants, friends, family members

•limited window of opportunity

•randomize optotypes, use reinforcers

•test=game, be creative

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

E• Lea Symbols

• Teller Acuity Cards

• OKN

F PT O Z

H O V T

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Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen• Broken Wheel• HOTV• Lea Symbolsy• Teller Acuity Cards• OKN• Cardiff Cards

preferential looking cards that use form discrimination with vanishing optotypes

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Visual Acuity Refractive Error

Mohindra Dynamic Retinoscopy

•lens bars, 50 cm working distance, g•dark, pt looks at light•neutralize primary meridians•write in spherocyindrical form•add a (-) minus 1.25 to the sphere

Refractive Error

• Cycloplegic/Mydriatic spray

• Spray on closed lids, have pt blink wipe off have pt blink, wipe off excess (.5% Cyclo, .5% Myd, 2.5% Phenyl)

Refractive Error

• Keratometry• hand held electronic devices (Nidek)• Placido’s disk• keratoscope

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• A l K• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

Incidence of Strabismus

CEREBRAL PALSY 15-60%

MENTAL RETARDATION 16-40%

• Observation

• Cover Test

• Bruckner

DOWN SYNDROME 41-75%

DEAFNESS 29%

NORMAL CHILDREN 2-4%

• Angle Kappa

• Hirschberg

• Krimsky

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Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• A l K• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• A l K• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• A l K• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• A l K• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint p

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint p

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

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Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint Retinoscopyp py

• NPC

• Accommodative Facility

• Saccades/Pursuits http://opt.pacificu.edu/ce/catalog/14041-GO/14041-GO.html

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint p

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint p

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint p

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Ocular Health

•Hand held devices•Slit lamp•Tonopen/PerkinsTonopen/Perkins•BIO/MIO/direct

http://opt.pacificu.edu/ce/catalog/14041-GO/14041-GO.html

Ocular Health

•Hand held devices•Slit lamp•Keeler/Tonopen/•Perkins•Perkins•BIO/MIO/direct

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Ocular Health

•Hand held devices•Slit lamp•Tonopen/PerkinsTonopen/Perkins•BIO/MIO/direct

Tangential Penlight Angle Estimation

• Penlight at temporal aspect of cornea

• Angle between 20-35 degrees to the facial planethe facial plane

• Maximum brightness

• Open angle = nasal illumination at least 75% as bright as temporal illumination

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA• TOVA

• Visagraph

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA

Ultrasound, B-Scan

CPT 76512 (contact B-scan);

IndicationsExamination of the posterior

• TOVA

• Visagraphportion of the eye when direct view is precluded by media opacities. Evaluation of intraocular or orbital masses.

For more info:

http://www.healthgate.co.uk/dp/dph.0253.shtml

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA

The Test of Variables of Attention (T.O.V.A.®),

a 21.6 minute computerized continuous performance test used by professionals in the diagnosis and monitoring

of treatment of attention deficit disorder (ADD)/attention deficit hyperactivity • TOVA

• Visagraph

( ) yp ydisorder (ADHD) in children and adults. The standardized test is well normed and extremely helpful in predicting responsiveness to treatment modality.

More info at: http://www.tova.net/

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA• TOVA

• Visagraph

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Assessment

• Working with incomplete or “fuzzy” clinical data

• “Get over it!”

• Seek helpSeek help• Dr. Dominick Maino• 312-949-7282• dmaino@ico.edu

Treatment

• Refractive

•Patient’s cognitive level•Patient’s motor ability•Patient’s therapy goals•Patient’s vocational goals•Patient’s self abusive behaviors•Living conditions•Past success

Treatment

• When Do You Correct Refractive Error?

•Myopia > 1.00D•Hyperopia > 2.00Dyp p•WR Astig > 2.00D•AR Astig > 1.00D•Oblique Astig > 1.00D•Anisometropia > 1.00D

Treatment

• Binocular Vision Dysfunction• Strabismus

• Rx, VT, surgery• Amblyopia

• Rx VT• Rx, VT• Accommodation dysfunction

• Rx, VT• Oculomotor anomalies

• Rx, VT

Treatment

Ocular Health

Treat as you would any other patient. May even be more aggressive in your treatment

Treatment

Ocular Healthanterior segment:

lids, lashes

conjunctiva, cornea

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Treatment

• Lens• refer/treat optically• cataract• lenticonus

• Fundus/Optic nerve• diagnose/refer

Treatment

• GLC•Treat/Refer•Many need

i l surgical intervention

Referral Resources

Developmental Disabilities Service

Neumann Family Services of the

Illinois Eye Institute3241 S. Michigan Ave.

Chicago, Il. 60616

312-949-7280 (Pediatrics)

Summary

• All deserve optometric vision care

• If all you do is take a detailed case history, it’s probably more than any have even attempted before

d i h f l• Do not underestimate the power of glasses

• Be creative, use want you know, invent!

• Treat (optically, functionally, medically) because we do it all!

Questions? Contact:

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

Professor, Pediatric/Binocular Vision ServiceDistinguished Practitioner, Academies of Practice

Leonardo da Vinci Award of Excellence in Medicine, Recipient

Illinois Eye Institute Illinois College of Optometry

3241 S. Michigan Ave. Chicago, Il. 60616

312-949-7280 (phone) 312-949-7660 (fax)

dmaino@ico.edu www.ico.edu

www.nw.optometry.net MainosMemos.blogspot.com